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Reference  ?ttbrarp 


Digitized  by  the  Internet  Archive 

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http://www.archive.org/details/handbookofinsaniOOkirc 


HANDBOOK 


INSANITY 


Practitioners  and  Students 


DR.  THEODORE  KIRCHHOFF 

PHYSICIAN   TO   THE    SCHLESWIG    INSANE    ASYLUM    AND    PRIVATDOCENT    AT    THE 
UNIVERSITY   OF   KIEL 


ILLUSTRATED  WITH  ELEVEN  PLATES 


NEW  YORK 

WILLIAM   WOOD    &   COMPANY 

1893 


Copyrighted,  1892 
WILLIAM  WOOD  &  COMPANY 


CONTENTS. 


GENERAL    PART. 


THE  ANATOMICAL  BASIS  AND  THE  LOCATION  OF  MENTAL 

DISTURBANCES. 

I 

Introduction,  .......... 

The  Brain  as  the  Site  of  Normal  Mental  Processes,     . 

Conclusions  from  the  Developmental  Histoiy  and  the  Structure 
of  the  Brain, 

The  Site  of  Mental  Disturbances  in  the  Brain  Based  on  Patho- 
logical Anatomy  and  Explained  by  Psychological  Con- 
siderations,     .         . ' 


B. 


II. 

CLASSIFICATION,    IMPORTANCE,    AND  MODE  OF  ACTION   OF  THE 
CAUSES  OF  INSANITY. 

Causes  Acting  upon  the  Community,     .         .         .         .         .21 

Civilization,  .........     21 

Race  and  Nationality  ;  Geographical  Position,  Soil,  Food  ; 

Seasons  and  Climate, 23 

Sex  and  Social  Position  ;  Age,    ...         .         .         .         .24 

Heredity, .         .29 

Crime  and  Genius ;  Education,  ......     32 

Occupation, 33 

Causes  which  Act  only  upon  the  Individual,          .         .         .33 
Bodily  Causes. — The  Brain  and  its  Membranes,         .         .33 
Coincident    Diseases    of    the  Cord,  Nerves,  and    Sympa- 
thetic,         35 

Anaemia  and  Exhausting  Diseases  of  Internal  Organs,      .     36 
Diseases  of  the  Sexual  Organs  and  Disturbances  of  their 
Function,  .........     37 

Febrile  Disease  and  Poisoning,  ......     39 

Psychical  Causes,  ........     42 


IV 


CONTENTS. 


III. 

THE   SIGNS  OF  MENTAL  DISORDERS. 

PAGE 

Introduction, 45 

A.  The  Disturbances  of  Consciousness, 46 

1.  Disturbances  of  the  Perceptive  Process,         .         .         .46 

2.  The   Disturbances  of  Consciousness  during  Sleep  and 

Dreams ;   Associated  States   of  Impaired  Conscious- 
ness and  Hypnotic  Conditions, 62 

3.  Disorders  of  Self- Consciousness,     .         .         .         .         .66 

B.  Disturbances  in  the  Association  and  Course  of  Ideas,   .         .     68 

1.  Apperception  and  Association,       .         .         .         .         .68 

2.  Accelerated  and  Retarded  Course  of  Ideas,  .         .         .70 

3.  Delusions, 72 

4.  Disorders  of  Memory  and  Fantasy,         ...         .         .  '  78 

C.  Disorders  of  Emotional  Life 84 

1.  Affects,  Sensual  and  Higher  Feelings,  .         .         .         .84 

2.  Terror  and  Allied  Feelings, 89 

D.  Disorders  of  Volition  and  Action, 91 

1.  Impulsive  Movements, 91 

2.  Expressive  Movements,  .         .         .         .         .  '      .         .  100 

E.  Concomitant  Physical  Symptoms,  ......  107 


IV. 

THE  COURSE  OF  MENTAL  DISORDERS. 

A.  Course,  Duration,  and  Termination, 

B.  General  Prognosis, 


114 

122 


V. 

THE  DIAGNOSIS  OF  MENTAL  DISORDERS  AND  THEIR  BORDER  LINES. 


A.  General  Standpoint, 

B.  Psychiatric  Examination, 

1.  Diagnosis  of  the  Disease, 

2.  Diagnosis  of  Recovery,   . 

C.  The  Border  Line  of  Insanity, 

D.  Post-Mortem  Findings,    . 


129 
131 
131 
145 

147 
150 


VI. 


THE   TREATMENT  OF  INSANITY. 


A.  Psychical  Treatment, 151 

B.  Prevention  of  Insanity, 154 


CONTENTS. 


C.  Bodily  Treatment, 

1.  General  Standpoint  and  Modes  of  Treatment, 

2.  Hypnotics, 

3.  Treatment  of  Important  Symptoms, 

D.  Asylums  and  their  Advantages,       ... 

E.  Treatment  of  Convalescents,    .         .         . 


PAGE 

,  155 

.  155 

.  158 

.  161 

.  166 

.  166 


VII 

HISTORY  OF  PSYCHIATRY,        ....    168 

A.  Antiquity, .         .   168 

B.  Middle  Ages  and  Modern  Times, 170 

C.  Gradual  Reform  of  Psychiatry  in  the  Past  Hundred  Years,   .  174 

1.  Erection  of  Insane  Asylums,  .....   174 

2.  Opposition  to  Mechanical  Restraint,      ....   175 

D.  Present  Treatment  of  the  Insane, 178 


SPECIAL    PART. 


CLASSIFICATION  OF  INSANITY, 


.    183 


II. 


SIMPLE   MENTAL   DISORDERS. 


A.  Melancholia,     . 

.  186 

B.  Mania,       .... 

.   201 

C.  Periodical  Forms,     . 

.   216 

Periodical  Melancholia, 

.  218 

Periodical  Mania, 

.   220 

Circular  Insanity,     ~    . 

.    223 

D.  Paranoia, 

.   230 

1.   Walmsinn, 

.   231 

2.  Verruecktheit, 

.  236 

3.   Confusion, 

.  254 

III. 

MENTAL     DISORDERS    ASSOCIATED     WITH    PERMANENT     ANATOMICAL 
CHANGES  IN  THE  BRAIN   OR  WITH  GENERAL  DISEASES. 


Introduction, 

A.  Dementia, 

B.  Senile  Dementia, 


258 
259 
262 


VI 


CONTENTS. 


C.  Paralytic  Dementia,         .... 

D.  Other  Forms  of  Dementia  with  Paralysis, 

Cerebral  Syphilis,         .... 
Focal  Diseases  of  the  Brain, 

E.  Mental  Disease  in  Epilepsy,     . 

F.  Insanity  and  Hysteria,     .... 

G.  Mental  Disorders  with  Neurasthenia,     . 

Chronic  Forms,    ..... 

Acute  Forms, 

H.   Mental  Disorders  Due  to  Poisons,  . 

J.  Feeble-mindedness  (Imbecility  and  Idiocy), 


PAGE 

266 
296 
296 
300 
301 
311 
320 
320 
330 
332 
346 


GENERAL   PART. 


HANDBOOK  OF  INSANITY. 


THE  ANATOMICAL  BASIS  AND  THE  LOCATION  OF  MENTAL 
DISTURBANCES. 

Introduction. 

Psychiatry  is  the  science  of  mental  disturbances  and 
their  treatment.  It  is  an  empirical  science,  whose  contents 
are  furnished  by  external  and  internal  experience,  i.e.,  by- 
objective  observations  on  the  patient  and  by  the  subjective 
observations  which  the  patient  makes  upon  himself.  The 
internal  experience  escapes  the  physician  much  more  read- 
ily than  in  other  medical  sciences.  The  mental  processes 
of  other  individuals  are  only  in  part  accessible  to  obser- 
vation, in  so  far  as  they  can  be  communicated  by  speech, 
gestures,  and  actions.  The  internal  bodily  activity  which 
takes  place,  for  example,  between  a  stimulus  and  a  sensa- 
tion, and  is  called  psychophysical,  occurs  in  an  inter- 
vening link,  viz.,  the  brain  or  organ  of  psychophysical 
activity.  Here  is  the  boundary  tract  in  which  the  links 
in  the  chain  of  stimulus  and  sensation  come  in  contact. 
In  the  investigation  of  this  tract,  psychiatry  requires  the 
aid  of  psychology. 

In  so  far  as  the  mental  processes  depend,  outside  of  this 
boundarj^  tract,  upon  the  basis  of  the  physical  functions, 
especially  upon  the  brain,  a  field  of  investigation  which 
is  positively  comprehensible  is  open  to  observation,  and 
we  are,  in  a  measure,  justified  in  looking  for  the  symp- 
toms of  a  mental  disturbance  in  changes  of  the  physical 
basis.      In  order  to  understand  the  symptoms  we  must 

3 


4  HANDBOOK   OF   INSANITY. 

first  endeavor  to  find  the  location  and  character  of  the 
anatomical  changes.  But  anatomy  alone  does  not  suffice 
for  a  thorough  understanding.  We  must  not  desist  en- 
tirely from  the  attempt  to  investigate  the  intermediate 
processes  which  lead  from  external  to  internal  experience. 
Hence  the  relation  of  bodily  and  mental  disturbances  must 
be  made  clear  by  the  intimate  association  of  cerebral 
pathology  and  psychopathology. 

The  Brain  as  the  Site  of  Normal  Mental  Processes. 

Anatomically  the  brain  is  the  rallying-point  of  almost  all 
the  spinal  systems  of  fibres ;  in  addition  the  most  varied  as- 
sociation-systems are  present  in  the  cerebrum  itself.  Com- 
parative anatomy  teaches  that  relatively  to  the  size  of  the 
body  the  size  of  the  cerebral  lobes  increases,  in  general, 
with  the  intelligence  of  the  animal.  The  same  relation  is 
shown  in  the  increasing  development  of  the  surface  of  the 
brain  by  fissures  and  convolutions,  and  for  this  reason  the 
cortical  gray  matter  is  universally  regarded  as  an  espe- 
cially important  part  of  the  cerebrum.  As  a  rule,  individ- 
uals of  great  mental  activity  possess  very  large  brains, 
with  a  marked  development  of  the  surface.  It  is  probable 
that  great  importance  also  attaches  to  the  thickness  of  the 
cortex. 

Developmental  history  shows  that  the  development  of  the 
surface  and  the  mass  of  individual  parts  does  not  always 
coincide  in  point  of  time  with  the  appearance  of  higher 
mental  activities,  but  that  it  precedes  the  latter  in  a  cer- 
tain measure.  The  association-fibres  in  the  cerebral  cortex 
develop  within  the  first  year  of  life,  and  it  is  not  until  the 
age  of  seven  to  eight  years  that  they  attain  the  arrange- 
ment which  is  permanent  in  adults.  The  development  of 
these  fibres  occurs  latest  in  the  frontal  lobes. 

A  further  argument  in  favor  of  the  view  that  the  mental 
processes  take  place  in  the  brain  is  furnished  by  self- 
observation  during  mental  processes,  which  are  accom- 
panied by  very  feeble  sensations  in  the  brain. 


DEVELOPMENT   OF   BRAIN.  5 

The  assumption  that  the  brain  is  the  site  of  mental 
activity  is  rendered  very  probable  by  the  above  statements, 
and  this  is  confirmed  by  our  experience  concerning  morbid 
changes.  Before  proceeding  to  the  consideration  of  path- 
ological conditions,  we  must  first  recall  some  data  con- 
cerning the  developmental  history  and  structure  of  the 
brain. 

Conclusions  from  the  Developmental  History  and  the 
Structure  of  the  Brain. 

The  mode  of  development  of  certain  brain  fissures  is 
important.  The  Sylvian  fissure  is  associated  intimately 
with  the  development  of  the  basal  ganglia,  in  whose  vi- 
cinity the  cerebral  wall  grows  more  slowly  and,  therefore, 
remains  in  a  depression;  this  part  is  known  as  the  Island 
of  Reil.  The  three  so-called  total  fissures,  viz.,  the  hippo- 
campal,  calcarine,  and  occipito-parietal,  are  developed  in 
an  entirely  different  manner.  They  appear  in  the  third  and 
fourth  months  of  fcetal  life.  The  hollow  medullary  tube 
of  the  embryo  then  possesses,  at  its  anterior  extremity, 
several  vesicular  dilatations;  especially  important  is  the 
most  anterior  or  fore-brain  vesicle,  from  which  the  two 
cerebral  hemispheres  develop.  The  mass  of  the  thin  wall 
of  the  fore-brain  vesicle  now  grows  more  rapidly  than  the 
inclosing  skull,  which  has  become  cartilaginous.  Hence 
folds  develop  toward  the  side  of  least  resistance,  i.e.,  into 
the  cerebral  ventricles;  they  extend  through  the  entire 
thickness  of  the  cerebral  wall,  and  are,  therefore,  called 
total.  As  a  permanent  expression  of  this  process  the  adult 
brain  contains  in  the  inferior  horn  of  the  lateral  ventricle, 
and  corresponding  to  the  hippocampal  fissure,  the  Am- 
nion's horn  or  pes  hippocampi  major.  In  the  posterior 
horn  the  pes  hippocampi  minor  is  found  beneath  the  cal- 
carine fissure.  A  prominence  which  corresponds  to  the 
parieto-occipital  fissure,  and  is  very  distinct  in  the  fcetal 
brain,  is  obliterated  in  the  adult. 

All  the  other  principal  fissures  do  not  correspond  to  pro- 


6 


HANDBOOK   OF   INSANITY. 


jections  into  the  lateral  ventricles,  and  are  due  to  local  ele- 
vations of  the  adjacent  cerebral  cortex.  The  coarser  vas- 
cular arrangements  are  probably  important,  because  the 
fissures  contain  the  larger  veins,  and  it  may  be  assumed 
that  the  resistance  of  the  latter  gives  rise  to  these  cortical 
fissures. 

But  even  the  total  fissures  do  not  develop  entirely  on 
account  of  differences  in  the  growth  of  the  cortex.  The 
parieto-occipital  fissure  is  supplied  solely  by  the  arteria  pro- 
funda cerebri,  the  hippocampal  fissure  by  the  arteria  cor- 
poris callosi,  and  the  course  of  the  middle  cerebral  in  the 
Sylvian  fissure  also  indicates  a  connection  between  the 


Fig.  1. 


vascular  development  and  the  growth  of  the  surface. 
Furthermore,  the  most  important  so-called  cortical  centres 
are  situated  around  the  fissures  which  appear  earliest  and 
are  best  supplied  with  blood. 

In  view  of  these  data  the  significance  of  the  fissures  is 
easily  understood.  They  may  also  be  regarded,  in  part, 
as  nutritive  grooves,  inasmuch  as  the  vessels  often  enter 
the  pre-formed  fissures.  The  large  size  and  extent  of  the 
pia  mater  probably  depend,  however,  on  the  nutritive  needs 
of  the  brain,  which  contains  approximately  one-fifth  of  the 
entire  mass  of  blood  in  the  body.  Although  the  vessels  do 
not  cause  the  development  of  the  fissures,  the  distribution 
of  the  former  by  different  arrangements  of  the  fissures  must 


DEVELOPMENT   OF   BRAIN. 


exercise  great  influence  on  the  activity  of  the  correspond- 
ing parts  of  the  brain,  and  it  is  probable  that  for  this  rea- 
son the  activity  of  the  same  cortical  regions  will  differ  in 
different  individuals.  Hence  arises  the  necessity  of  accu- 
rate topographical  investigation  of  the  cerebral  cortex  as 
regards  the  local  differences  in  the  healthy  and  diseased 
human  brain. 

In  the  third  foetal  month  the  layer  of  gray  matter  is 
almost  one-fourth  the  thickness  of  the  hemispheres,  but 
in  the  fourth  month  it  diminishes  to  one-seventh.  Va- 
rious layers  are  found  even  before  this  period ;  a  deeper 
layer  of  cellular  elements  often  exhibits  a  wave-shape, 


Fig.  2. 


while  the  outer  boundary  still  runs  in  a  straight  line.  In 
the  middle  of  the  layer  of  cellular  elements,  and  also  in  a 
deeper  layer,  light  bands  appear,  at  the  latest  during  the 
fifth  month.  But  some  of  the  cellular  layers  unite  and 
disappear  during  the  later  fcetal  months,  so  that  their  per- 
manent arrangement  can  only  be  studied  in  the  new-born. 
In  the  fifth  month  a  distinct  nucleolus  sometimes  appears 
in  the  round  nuclei  of  certain  cell-layers;  a  few  nuclei 
have  short  processes  so  that  they  appear  angular. 

Ganglion  cells  are  only  recognizable  in  the  cortex  of  the 
fully  developed  foetus ;  indeed,  distinct  boundaries  of  pyra- 
midal cells  are  found  only  in  infants  of  one  to  two  months, 
and  even  here  they  are  mingled  with  imperfectly  developed 
cells. 


8  HANDBOOK   OF   INSANITY. 

The  simplest  classification  recognizes  an  external,  mid- 
dle, and  internal  layer.  At  the  beginning  the  cells  are 
arranged  like  a  string  of  pearls  from  without,  inward ;  or 
we  may  speak  of  a  palisade-like  or  columnar  arrangement 
of  the  rows  of  cells.  This  is  most  distinct  during  the  first 
foetal  months;  later  the  cells  are  arranged  more  closely 
together,  and  the  longitudinal  streaks  are  somewhat  oblit- 
erated by  the  transverse  layers.  Even  after  the  formation 
of  the  fissures,  rows  of  granules  may  be  followed  close  to 
the  border  of  the  cortex ;  if  nerve-fibres  have  formed,  they 
can  usually  be  followed  only  to  the  middle  layer,  where 
they  radiate  like  a  brush,  and  thus  remain  parallel  to  the 
surface  only  at  the  trough  of  the  fissures,  while  at  the 
cap  they  break  through  the  layers  to  the  outer  boun- 
dary. This  difference  in  the  course  of  the  medullary  fibres 
and  cell-layers  in  the  trough  of  the  fissures  and  the  apex 
of  the  convolutions  is  important  in  regard  to  the  physio- 
logical connection  between  association-fibres  and  ganglion 
cells ;  it  indicates  that,  in  this  relation,  greater  importance 
is  to  be  attached  to  the  apex  of  the  convolutions. 

It  is  also  important  to  know  that  the  fibres  of  the  coma 
radiata  radiate  chiefly  in  the  apices  of  the  convolutions, 
the  association-fibres  in  the  troughs  of  the  convolutions, 
and  that  the  growth  of  these  different  systems  together  has 
given  rise  to  the  convolution  of  the  cortex. 

A  few  regions  of  the  cortex  can  be  distinguished  by  a 
special  arrangement  of  the  layers  and  cells.  As  a  general 
thing,  these  regions  also  possess  special  functions.  The 
centromotor  region  alone  contains  the  so-called  giant-cells ; 
the  speech  region  alone  contains  a  large  accumulation  of 
spindle-cells ;  the  visual  region  alone  contains  the  peculiar 
lamination  of  the  Vicq  d'Azyr's  stripes,  and  the  assumed 
olfactory  and  tactile  region  possesses  the  peculiar  structure 
of  the  hippocampal  convolution  and  its  appendages.  The 
remainder  of  the  cortex  exhibits  no  striking  differences. 

I  will  not  enter  into  a  description  of  the  important 
commissural  systems.  Apart  from  the  association-fibres 
already  mentioned,  I  will  merely  refer  to  the  corpus  cal- 


SITE   OF   MENTAL   DISTURBANCES.  9 

losum,  which  connects  the  hemispheres.  These  two  sys- 
tems prove  that  definite  regions  of  the  brain  are  physio- 
logically associated. 

The  Site  of  Mental  Disturbances  in  the  Brain  Based  on 
Pathological  Anatomy  and  Explained  by  Psycho- 
logical Considerations. 

It  must  be  our  first  object  to  ascertain  to  what  extent 
focal  diseases  have  aided  in  our  knowledge  of  the  location 
of  mental  disturbances.  In  so  far  as  the  lesions  have 
interrupted  conduction  systems,  they  have  not  taught  as 
much  as  disease  of  the  centres,  and  it  has  been  found  that 
the  interruption  of  certain  systems  of  fibres  leading 
from  the  cerebrum  to  the  cerebellum  gives  rise  to  distinct 
slowness  and  difficulty  of  the  mental  functions.  Among 
the  large  ganglia  the  optic  thalamus  seems  to  possess  more 
intimate  relations  to  the  higher  mental  functions  than 
does  the  corpus  striatum,  inasmuch  as  the  former  alone 
undergoes  atrophy  in  congenital  absence  of  the  cerebral 
hemispheres.  The  disturbance  in  the  intellectual  develop- 
ment of  individuals  in  whom  the  corpus  callosum  is  absent 
or  only  very  small,  indicates  that  the  higher  mental  pro- 
cesses are  not  dependent  upon  the  frontal  brain  alone; 
indeed,  in  these  cases,  the  occipital  lobes  are  mainly  atro- 
phied. If  the  brain  is  imperfectly  developed  as  a  whole, 
as  in  some  idiots,  there  can  be  no  question  of  localization. 
Nor  is  any  further  conclusion  warranted  from  irregular 
development  in  the  cortical  layers,  unless  it  is  circum- 
scribed. For  example,  in  a  few  idiots  the  frontal  lobes 
contained  only  very  narrow  pyramidal  cells,  which  were 
distributed  irregularty,  so  that  it  was  almost  impossible 
to  distinguish  the  layers.  Here  the  imperfect  mental  de- 
velopment may  be  attributed  to  the  imperfect  development 
of  the  frontal  cortex. 

Description  of  Figs.  3,  4,  and  5,  which  are  made  according  to 
Ecker's  brain-scheme,  with  the  aid  of  the  literature  of  the  locali- 
zation question. 


10 


HANDBOOK    OF    INSANITY. 


The  dotted  line  gives  a  schematic  posterior  boundary  of  the 
apperception  organ  in  the  frontal  brain,  and  the  anterior  boundary 
of  the  perception  organ  in  the  occipital  and  parietal  lobes.  This 
line  incloses  the  centro-motor  region.     These  three  tracts  coincide 


AH^cerebrimedu 


approximately  with  the  areas  of  distribution  of  the  anterior,  pos- 
terior, and  middle  cerebral  arteries.     The  fact  that  the  centres  for 


ci»J£C^- 


Fig.  4. 


speech  and  writing  (which  are  developed  in  one  hemisphere  alone) 
are  not  contained  in  our  centro-motor  region,  proves  the  merely 
schematic  value  of  the  division  ;  nevertheless  these  two  important 


CORTICAL   CENTRES. 


11 


centres  are  in  close  proximity  to  this  region.  For  purposes  of 
teaching  we  require  a  sharp  separation  of  the  centres,  which  in 
reality  often  pass  into  another.  The  speech-region,  in  particular, 
must  be  regarded  as  a  composite  cortical  region.  Only  the  corners 
of  the  speech-region  are  formed  by  its  centres,  while  the  corti- 
cal fields  of  the  optic  and   auditory  nerves,  as  well  as  of  various 


Fig.  5. 

motor  nerves,  anastomose  at  the  edges  with  the  speech -centre. 
Hence  the  interruption  of  the  afferent  connections  of  adjacent 
sensory  regions  at  these  edges  will  give  rise  to  speech -disturbances, 
as  well  as  the  destruction  of  more  central  parts. 

1.  Centre  for  motor  aphasia  (Broca's  region).     Speech  images. 

2.  Centre  for  sensory  aphasia  (Wernicke's  region.)    Speech  images.     Auditory 
centre.     Word-deafness. 

3.  Hypoglossal  field. 

4.  Facial  field  (inferior  branches). 

5.  Motor  trigeminus  field  (portio  minor). 

6.  Centre  for  agraphia.     Writing  images. 

7.  Centre  for  coarse  arm  movements. 

8.  Centre  for  coarse  leg  movements. 

9.  Centre  for  coarse  arm  and  leg  movements. 

10.  Centre  for  complicated  movements  of  hand,  arm,  and  leg. 

11.  Supposed  centre  for  levator  palpebrae  superioris. 


12  HANDBOOK    OF    INSANITY. 

12.  Centre  for  disturbances  in  all  sensory  tracts. 

13.  Centre  for  alexia.     Writing  images.     Word-blindness. 

14.  Visual  centre ;  *  indicates  macula  lutea. 

15.  Doubtful  centre  for  smell  and  taste ;  in  this  vicinity,  perhaps,  also  a  tactile 
centre,  including  sexual  feelings. 

The  reports  of  scattered  cases  in  which,  after  complete 
destruction  of  one  cerebral  hemisphere,  mental  disturb- 
ances did  not  set  in,  have  called  attention  to  the  possibility 
of  vicarious  activity  of  the  other  half  of  the  brain,  pro- 
vided that  both  halves  possess  originally  the  capacity  for 
exercising  the  same  functions.  The  question  of  the  co-or- 
dinate value  of  the  hemispheres  is  of  the  highest  impor- 
tance in  the  examination  of  the  site  of  individual  func- 
tions. The  relegation  of  speech-disturbances  to  the  left 
half  appeared  to  prove  their  unequal  value,  at  least  in  the 
exercise  of  their  functions,  while  it  allows  the  possibility 
of  the  development  of  this  function  in  each  hemisphere. 
For  a  time  the  notion  of  the  unequal  value  of  the  hemi- 
spheres was  supported  by  the  observation  that  the  left 
frontal  lobe  develops  more  rapidly  and  abundantly  than  the 
right.  It  was  also  shown  that,  in  mental  strains,  the 
left  forehead  exhibits,  on  the  average,  a  somewhat  higher 
temperature  than  the  right  one.  Not  long  ago  the  site  of 
aphasia  was  confined  strictly  to  the  left  inferior  frontal 
convolution ;  at  the  present  time  other  cortical  regions  are 
known  to  possess  intimate  relations  to  aphasia.  These  are 
situated  in  the  vicinity  of  the  visual  centre  in  the  occipi- 
tal lobe,  and  of  the  acoustic  centre  in  the  superior  temporo- 
sphenoidal  convolution.  It  was  also  supposed  that  the 
localization  of  aphasia  in  the  left  hemisphere  was  ren- 
dered doubtful  by  the  observation  of  cases  of  aphasia  after 
lesions  of  the  right  hemisphere,  but  this  doubt  was  relieved 
by  the  proof  that  the  latter  cases  occurred  in  left-handed 
individuals,  who  favor  the  right  hemisphere  by  the  move- 
ments of  the  left  hand. 

The  function  of  speech  is  complicated,  and  it  is  neces- 
sary to  distinguish  several  varieties  of  aphasia.  The  loss 
of  the  power  of  hearing  words  causes  word-deafness ;  that 
•of  reading,  word-blindness;  the  loss  of  articulate  speech 


APHASIA.  13 

causes  motor  aphasia,  and  of  the  power  of  writing  agraphia. 
The  two  latter  groups  contain  the  principal  modes  of  ex- 
pression of  human  speech.  Gestures  accompany  speak- 
ing, and  both  are  usually  lost  at  the  same  time,  so  that 
pantomime  need  not  he  considered  separately.  The  views 
which  generally  obtain  at  the  present  time  are  shown  in 
Fig.   10,  and   comparison   with   Fig.    7   shows  that  the 


Fig.  6  (After  Ballet)  .  —a,  The  region  of  print  images ;  p,  the  region  of  lan- 
guage images ;  y,  the  region  of  the  speech  images ;  S,  the  region  of  writing  images. 

speech-centres  are  situated  between  the  centres  for  move- 
ments and  special  sense-impressions.  This  arrangement 
seems  to  show  the  close  relation  of  speech  to  all  the  other 
cortical  functions.  All  four  speech-centres  are  supplied 
by  the  middle  cerebral  artery,  which,  however,  also  sup- 
plies other  centres. 

The  manifold  character  of  the  symptoms  of  aphasia  is 
partly  explained  in  the  manner  just  indicated,  but  some 
cases  cannot  be  explained  by  anatomical  considerations 
alone,  and  require  psychological  examination.  Speech  is 
an  internal  and  external  process,  composed  of  conceptions 
and  words.  Aphasia  shows  that  the  word  does  not  neces- 
sarily accompany  the  conception.  The  word  is  a  collective 
notion,  arising  from  the  combination  of  several  varieties 
of  images  (auditory,  visual,  speech,  and  writing) .  These 
four  principal  components  of  the  word  are  formulae  which 
every  judgment  utilizes,  but,  according  to  the  tendencies 
and  abilities  of  the  individual  person,  they  appear  either 
in  varying  degrees  or  only  in  part  in  his  deliberations. 
The  purely  internal  processes  of  seeing,  hearing,  speak- 


14  HANDBOOK   OF   INSANITY. 

ing,  and  writing  are  entirely  similar  to  those  of  external 
speech,  but,  as  they  are  phenomena  "which  occur  within, 
they  must  be  distinguished  as  internal  speech.  Accord- 
ing as  the  internal  mental  processes  are  associated  exclu- 
sively or  chiefly  with  conceptions  of  language,  print, 
speech,  or  writing,  human  beings  may  be  divided  into 
groups,  viz.',  into  those  who  think  in  conceptions  of  lan- 
guage, print,  speech,  or  writing. 

Most  people  think  in  language  conceptions.  Auditory 
images  of  the  words  generally  accompany  our  conceptions ; 
we  hear  our  thoughts.  In  only  a  few  individuals  are 
thoughts  clothed  in  written  words ;  these  read  the  visual  im- 
ages of  their  conceptions.  This  is  most  marked  in  artists, 
who  remember  things  in  general  as  memory-pictures.  In 
them  speech-conceptions  appear  in  the  form  of  writing-im- 
ages. Individuals  in  whom  the  memory  of  the  movements 
of  speaking  or  writing  accompany  the  conceptions,  speak  or 
write  their  thoughts  internally ;  the  corresponding  feelings 
of  movement  are  closely  associated  with  every  thought. 
Cases  of  association  of  thoughts  with  writing-movements 
are  probably  rarer  than  those  associated  with  speech-move- 
ments. But  we  generally  employ  alternately  this  or  that 
form  of  internal  speech,  otherwise  the  loss  of  one  form  would 
entail  complete  loss  of  speech.  As  language- images  are  first 
acquired,  the  other  forms  are  often  of  inferior  importance. 
It  is  important,  from  this  standpoint,  to  know  the  physio- 
logical brain  formula  of  a  patient,  i.e.,  the  physiological 
variations  in  the  course  of  his  speech-conceptions  which 
are  due  to  his  personality.  Such  considerations  throw 
some  light  on  the  location  of  speech-conceptions  and  their 
disturbances.  The  early  development  and  better  nutri- 
tion of  the  left  hemisphere,  together  with  the  better  devel- 
opment of  the  centres  of  movement  of  the  right  hand, 
harmonize  with  the  fact  of  the  localization  of  the  speech- 
centre  in  the  left  hemisphere.  The  other  forms  of  dis- 
turbance, viz.,  word-blindness  and  word-deafness,  are 
situated  more  frequently  on  the  right  side,  and  thus  the 
entire  cortex  remains  the  site  of  language-conceptions. 


LANGUAGE.  15 

Language  possesses  the  most  manifold  relations  with 
the  totality  of  mental  life.  Almost  every  mental  disturb- 
ance is  composed  of  the  most  complicated  phenomena,  and 
we  find,  accordingly,  that  the  cerebral  lesions  of  insanity 
are  diffused  over  the  cortex ;  the  circumscribed  lesions  of 
other  clinical  complexes  only  indicate  individual  places, 
to  which  part-symptoms  are  due.  Another  inference  may 
be  drawn  from  the  psychological  consideration  of  lan- 
guage. There  are  hallucinations  which  belong  to  the 
most  important  signs  of  insanity;  they  are  to  be  regarded 
as  disturbances  of  conception,  produced  locally  in  the  cor- 
tex, and  in  which  the  individual  can  no  longer  distinguish 
between  the  internal  processes  and  their  external  causal 
conditions.  In  this  sense  we  may  distinguish  internal  from 
external  vision,  etc.  If  the  ability  to  differentiate  is  want- 
ing, an  hallucination  is  present,  dependent  upon  processes 
in  those  parts  of  the  brain  which  preserve  memory-pictures 
of  the  most  varied  kinds.  Interpreted  in  this  way  every 
mental  disturbance  is  essentially  a  disturbance  of  memory, 
the  primary  function  of  brain-matter. 

Another  observation  which  increases  the  importance  of 
diffuse  anatomical  changes  in  speech-disturbances  is  the 
fact  that  diffuse  diseases  appear  to  be  attended  with  much 
more  marked  disturbances  of  mental  activity  than  cases 
in  which  there  are  focal  lesions.  A  further  peculiarity  is 
the  increase  in  the  intensity  of  mental  disturbances  with 
the  increase  in  the  distance  of  the  anatomical  changes 
from  the  inferior  frontal  convolution  and  their  approxi- 
mation to  the  occipital  lobes.  It  is  certain  that  the  more 
remote  centres  of  sensory  impressions  in  the  occipito-tem- 
poral  lobes  (perception  organ)  are  more  important  in  regard 
to  the  higher  mental  activities  than  the  adjacent  motor- 
centres.  In  psychoses  we  must  regard  aphasic  conditions, 
in  so  far  as  they  develop  in  the  cortex,  as  dependent,  not 
on  circumscribed,  but  on  diffuse  lesions. 

Two  cortical  regions  possess  comparatively  simple  rela- 
tions to  the  higher  psychical  functions,  viz.,  the  centro-mo- 
tor  and  visual  centres.     We  must  distinguish  atactic  and 


16  HANDBOOK   OF   INSANITY. 

paralytic  disturbances  according  as  the  anatomical  changes 
are  situated  in  the  parietal  lobe,  or  in  the  central  convolu- 
tions and  paracentral  lobules.  Although  we  cannot  assume 
that  the  higher  processes  of  consciousness  necessary  to  the 
execution  of  movements  develop  in  these  centres,  neverthe- 
less they  constitute  indispensable  transition  places  for  such 
processes.  With  every  disturbance  of  function  in  any 
part  of  the  cortex,  there  is  naturally  restriction  of  the  con- 
tents of  consciousness,  inasmuch  as  the  paths  of  mental 
processes  extend  over  the  entire  surface. 

We  will  now  consider  the  disturbances  of  visual  percep- 
tion. If  the  cuneus  and  the  first  occipital  convolution 
are  injured,  simple  optical  perception  is  destroyed ;  in  uni- 
lateral lesions  this  disturbance  is  an  hemianopsia,  in  bilat- 
eral lesions,  complete  blindness.  After  injury  of  the  re- 
maining occipital  convolutions  retinal  impressions  are  no 
longer  utilized  psychically.  This  experience  is  confirmed 
by  the  visual  hallucinations  observed  in  insanity,  espec- 
ially in  general  paresis,  and  which  preceded  diffuse  changes 
in  these  parts  of  the  brain.  We  have  to  deal  here  with  irri- 
tative processes  in  those  parts  of  the  cortex  in  which  other 
lesions  cause  hemianopsia  and  blindness.  This  is  con- 
nected with  a  peculiar  theory  concerning  different  degrees 
and  forms  of  visual  disturbances,  and  which  has  led  to  the 
assumption  of  a  color,  space,  and  light  sense.  The  patho- 
logical changes  are  confined  occasionally  to  certain  ones 
of  the  different  layers  of  the  cortex.  The  superficial  lesions 
of  the  cortex  then  cause  loss  of  the  color  and  space  sense, 
while  loss  of  the  light-sense  arises  from  deeper  destructions 
of  the  cortex.  This  theory,  however,  has  not  been  posi- 
tively proven.  There  is  no  doubt,  however,  that  the  visual 
disturbances  of  dementia  paralytica  are  localized  in  the 
region  mentioned.  This  disease  also  presents  other  local- 
izable  phenomena,  such  as  diminished  intelligence  and 
will,  which  are  found  associated  with  diffuse  disease  of 
the  frontal  lobes.  They  constitute  the  chief  reason  for 
regarding  the  frontal  lobes  as  the  organ  of  apperception 
for  sensory  impressions. 


PATHOLOGICAL   ANATOMY.  17 

If  we  adhere  to  the  principle  that,  in  the  main,  diffuse 
lesions  give  rise  to  mental  disturbances,  it  is  evident  that 
the  frequent  absence  of  gross  anatomical  changes  is  ex- 
plained by  imperfect  methods  of  examination,  although  I 
believe  that  improved  methods  will  disclose  changes  in 
only  a  limited  number  of  psychoses.  Little  importance 
attaches  to  the  view  that  certain  psychoses  are  due  to  dis- 
eases of  the  skull  and  dura  mater.  Changes  in  these  parts 
generally  accompany  pathological  processes  in  the  cortex. 
It  must  be  remembered  that  the  blood  supply  of  the  dura 
mater  is  not  derived  from  the  same  vessels  as  that  of  the 
hemispheres.  Pathological  conditions  in  the  pia  mater 
are  more  constant  concomitants  of  diseases  of  the  cortex. 

A  more  definite  indication  of  the  localization  of  mental 
disturbances  is  afforded  by  the  following  findings:  In 
maniacal  conditions  red  softening  of  the  cortex  is  some- 
times found  in  layers ;  the  middle  layer  of  the  three  which 
are  visible  to  the  naked  eye  being  softened.  On  detaching 
the  pia  mater,  the  outer  layer  usually  follows.  More 
rarely  the  softening  affects  the  outer  layer  itself,  and  then 
the  surface  appears  rough  when  the  pia  mater  is  removed. 
In  the  rarest  cases  the  softening  occurs  at  the  boundary 
of  the  cortex  and  white  matter ;  an  exactly  similar  condi- 
tion is  sometimes  found  in  dementia  paralytica.  In  the 
latter  event  the  softening  is  due  to  degeneration  of  the 
medullary  fibres.  The  softening  in  mania  appears  to  be 
connected  with  the  mode  of  ramification  of  the  vascular 
trunks  of  the  cortex  in  three  superjacent  series.  In  a 
measure  we  are  then  justified  in  regarding  the  site  of  soft- 
ening as  the  site  of  greatest  irritation.  The  restriction  of 
anatomical  changes  to  individual  layers  is  also  found  in 
so-called  gliosis  and  miliary  sclerosis  of  the  cortex ;  tumor- 
like proliferations  of  the  glia  in  the  superficial  layer  of 
the  cortex,  with  formation  of  cavities  and  disappearance 
of  nervous  elements,  leads  to  symptoms  similar  to  those  of 
dementia  paralytica ;  in  other  cases  small  reddish  gray  dots 
are  situated  at  the  boundary  of  the  gray  and  white  matter. 
However,  none  of  these  peculiar  changes  enable  us  to  draw 
2 


18  HANDBOOK   OP   INSANITY. 

a  conclusion  with  regard  to  the  nature  and  mode  of  devel- 
opment of  the  mental  disturbance. 

Certain  chronic  changes  are  also  mere  results  of  the 
irritation,  not  its  causes. 

Somewhat  more  light  is  thrown  upon  the  subject  by  re- 
garding these  changes  as  nutritive  disturbances.  One 
difficulty  in  attempting  localization  from  this  standpoint 
is  owing  to  the  fact  that  focal  lesions  very  often  produce 
irritative  conditions  in  their  immediate  vicinity,  and 
these  lead  to  symptoms  which  are  otherwise  due  only  to 
diffuse  lesions.  Such  remote  effects  are  particularly  apt 
to  develop  on  a  vasomotor  basis. 

The  interpretation  of  certain  psychoses  as  nutritive  dis- 
turbances is  facilitated  by  the  following  considerations. 
In  the  foetus  and  early  infancy  tissue-necroses  are  more 
apt  to  occur  in  the  cortex  than  in  the  basal  ganglia,  because 
in  the  former  the  length  of  the  arteries  is  much  greater 
and  the  vessels  are  much  more  delicate  than  the  terminal 
arteries;  they  are,  therefore,  compressed  more  readily. 
These  conditions  are  most  unfavorable  in  the  vessels  of 
the  Sylvian  fissure  and  the  entire  motor  region.  The 
largest  terminal  branches  of  the  pia  mater  pass  to  the 
white  matter  beneath  the  cortex,  so  that  the  necroses  occur 
earlier  and  more  extensively  in  the  medullary  layer  than 
in  the  cortex.  This  medullary  layer  contains  the  layer  of 
the  association-tracts,  and  hence  small  lesions  give  rise  to 
great  gaps  in  the  psychical  processes.  These  observa- 
tions, however,  cannot  yet  be  utilized  in  the  explanation 
of  different  forms  of  disease. 

A  little  attention  must  here  be  devoted  to  the  considera- 
tion of  unilateral  hallucinations,  which  develop  in  the 
central  sensory  regions.  Unilateral  auditory  hallucina- 
tions are  comparatively  frequent,  and  in  a  few  cases  cor- 
tical lesions  of  the  opposite  cortex  were  found  on  autopsy, 
without  any  other  changes,  so  that  the  connection  was 
undoubted.  As  a  rule,  however,  the  lesions  cannot  be 
sharply  localized  when  there  are  extensive  affections  of 
the  cortex  or  where  several  senses  are  implicated. 

The  question  whether  individual  parts  of  mental  opera- 


LOCALIZATION   IN   INSANITY.  19 

tions  are  associated  with  definite  parts  of  the  cortex,  has 
lately  been  agitated  in  another  way.  Reference  has  been 
made  to  mental  focal  symptoms ;  attention  has  been  called 
to  the  fact  that  compound  mental  products,  such  as  con- 
cepts and  the  power  of  language,  are  acquired  singly  and 
may  also  be  lost  singly.  But  the  observations  in  this  cat- 
egory are  confined  to  a  few  clinical  cases  in  which  chiefly 
proper  names  and  numbers  were  forgotten,  or  foreign 
languages  were  forgotten  while  the  mother  tongue  was 
retained.  Anatomical  changes  in  layers  were  assumed, 
but  proofs  are  wanting.  It  must  also  be  remembered  that 
we  attribute  no  specific  functions  to  the  nervous  elemen- 
tary parts  of  the  brain.  Furthermore,  all  the  higher  mental 
activities  are  so  complicated  that  we  cannot  assume  that 
they  are  connected  with  simple  elements.  They  are  com- 
posed of  numerous  concepts  in  different  sensory  tracts. 
If  a  part  is  lost,  it  is  not  even  necessary  to  remind  our- 
selves that  other  parts  of  the  brain  may  act  vicariously, 
but  there  are  so  many  concepts  derived  from  other  sensory 
tracts  which  have  entered  consciousness  in  the  contents  of 
the  assumed  complicated  concept,  that  it  is  not  permissible 
to  speak  of  the  loss  of  an  individual  component  of  con- 
sciousness. All  internal  processes  constitute  conscious- 
ness ;  there  are  no  individual  modes  of  consciousness.  The 
processes  of  consciousness  are  dependent  on  the  entire 
nervous  system,  not  on  the  cerebral  cortex  alone. 

Taken  all  in  all,  the  attempts  at  localization  of  mental 
disturbances  possess  only  a  general  value.  Even  the  fact 
that  memory  is  sometimes  lost  only  in  part,  tells  us  noth- 
ing concerning  a  definite  site  of  the  loss  in  question. 
There  is  even  some  doubt  as  to  whether,  for  example,  the 
memory  of  a  certain  language  or  of  music  alone  may  be 
lost.  Greater  credibility  attaches  to  the  observation  that 
the  memory  of  proper  nouns  is  lost  more  easily  than  that 
of  common  nouns  and  adjectives.  But  there  are  no  cir- 
cumscribed affections  of  the  brain  which  teach  us  any- 
thing concerning  the  loss  of  such  local  memories.  Mental 
diseases  are  not  merely  diseases  of  the  brain  but  diseases 
of  the  person. 


II. 

CLASSIFICATION,    IMPORTANCE,    AND    MODE    OF    ACTION 
OF  THE  CAUSES  OF  INSANITY. 

The  causes  of  insanity  are  either  direct  and  immediate, 
or  indirect  and  predisposing.  The  latter  favor  the  devel- 
opment of  mental  disturbances  and  produce  a  predisposi- 
tion to  them.  In  the  individual  case  it  is  often  difficult 
to  decide  whether  we  have  to  deal  with  a  sign  of  the  dis- 
ease, i.e.,  with  an  effect  of  these  causes,  or  with  one  of 
the  causes  themselves.  Statistics  furnish  a  great  aid  in 
the  study  of  the  causes  of  insanity,  but  they  must  be  in- 
terpreted with  caution. 

Different  causes  are  so  often  combined  in  the  same  case 
that  we  are  hardly  ever  justified  in  making  a  single  one 
responsible  for  this  or  that  effect.  Hitherto  all  attempts 
at  etiological  classification  of  psychical  diseases  have  failed 
on  account  of  the  numerous  possibilities  in  each  case,  and 
also  because  an  entire  series  of  diseases  would  be  left 
without  a  known  cause. 

The  term  psychical  trauma  has  been  applied  recently 
to  constantly  repeated  injurious  influences  which  may 
produce  a  permanent  morbid  condition  in  certain  parts  of 
the  nervous  system.  It  is  interesting  in  this  respect  that, 
apart  from  distinct  mental  disorders,  some  of  the  lower 
functions  which  are  closely  related  to  emotional  and  men- 
tal activities  during  health  may  also  be  morbidly  changed 
in  the  same  way.  These  are  symptoms  such  as  palpita- 
tion, insomnia,  nervous  digestive  disorders,  laughing  and 
crying  spells — conditions  which  are  apt  to  develop  after 
continued  injurious  psychical  influences.  That  these  con- 
ditions are  not  morbid  per  se  is  evident,  because,  like 
redness  of  the  face  in  anger,  pallor  in  fright,  they  are 

20 


CIVILIZATION.  21 

perfectly  natural  results  of  their  antecedents.  But  if  they 
occur  in  uninterrupted  succession  the  injured  nervous 
system  constantly  reacts  in  this  way,  and  its  exhaustion  is 
an  evidence  of  the  morbid  condition.  (Here  we  may  prop- 
erly speak  of  a  psychical  injury,  a  trauma,  and  the  recog- 
nition of  the  casual  connection  shows  the  way  of  prevent- 
ing further  injury.)  Among  many  illustrations  of  psy- 
chical trauma,  we  will  mention  only  the  following :  The 
one-sided  method  of  tormenting  children  with  mechanical 
learning  by  rote  results  in  early  psychical  exhaustion ;  the 
constant  repetition  of  the  same  injurious  stimuli  rapidly 
leads  to  exhaustion  of  the  cerebral  activity,  which  either 
causes  disease  directly  or  predisposes  to  subsequent  dis- 
ease. In  this  way  the  effect  of  constantly  recurring  inju- 
rious influences  assumes  great  power.  We  will  now  con- 
sider the  predisposing  causes  according  as  they  affect  the 
community  or  the  individual. 

A.    CAUSES   ACTING  UPON   THE   COMMUNITY. 

Civilization. 

The  increasing  frequency  of  insanity  is  an  undoubted 
fact,  and  has  often  been  explained  by  the  advance  of  civil- 
ization.    This  is,  however,  only  true  in  a  measure. 

It  is  calculated  that,  in  civilized  nations,  there  is,  on 
the  average,  one  insane  individual  to  two  hundred  inhabi- 
tants, and  this  proportion  is  probably  below  the  truth. 
As  statistics  refer,  in  general,  only  to  recent  times,  I  will 
make  use  of  some  older  statistics  which  cover  a  small  dis- 
trict and  enable  us  to  make  a  comparison  between  former 
and  recent  times.  In  Schleswig-Holstein,  in  the  year 
1803,  there  were  700  insane  among  602,807  inhabitants, 
i.e.,  11  to  10,000.  In  1840,  there  were  2,125  insane  among 
772,974  inhabitants,  i.e.,  about  28  to  10,000.  In  1880, 
there  were  nearly  34  insane  to  10,000  inhabitants. 

The  value  of  statistics,  however,  is  impaired  by  several 
considerations.  In  the  first  place,  the  advance  of  civiliza- 
tion has  prolonged  the  life  of  the  insane,  and  thus  caused 


22  HANDBOOK   OF  INSANITY. 

an  apparent  increase  in  their  numbers.  Furthermore,  the 
increasing  care  with  which  statistics  are  obtained  must 
be  taken  into  consideration. 

The  chief  disadvantages  of  our  present  civilization  are 
clearly  evident  from  the  fact  that  the  increase  of  mental 
disorders  is  coincident  with  the  enormous  increase  in  the 
population  of  large  cities.  We  would  need  to  describe 
city  life  in  order  to  touch  upon  all  the  injurious  factors 
which  they  exhibit.  We  need  merely  mention  the  bad 
hygienic  surroundings,  poverty,  factory  life,  immorality, 
and  the  unmarried  state.  All  these  conditions  are  com- 
bined with  the  unceasing  struggle  for  existence. 

If  we  look  at  some  other  aspects  of  civilization  which 
obtain  not  alone  in  the  cities,  it  remains  doubtful  whether 
they  exercise  injurious  effects,  or  whether  some  of  them 
do  not  even  prevent  the  development  of  insanity.  Thus, 
it  is  questionable  whether  the  religious  and  political  con- 
vulsions of  our  times  are  etiological  factors.  Religious 
questions  absorb  the  public  interest  less  than  in  former 
periods.  Political  revolutions  are  attended  by  such  com- 
plicated factors,  that  it  is  hardly  possible  to  determine  sep- 
arately the  real  effect  of  the  political  condition.  It  is  in- 
teresting in  this  regard  that  among  the  French,  who  exhibit 
no  excessive  tendency  to  mental  disorders,  political  and  so- 
cial changes  appear  almost  with  a  certain  regularity.  The 
influence  of  such  events  appears  to  be  exerted  mainly  in  the 
character  and  complexion  of  the  disturbances,  rather  than 
in  a  notable  increase.  During  the  last  Franco-Prussian 
war  it  was  even  maintained  that  many  individuals,  who 
were  on  the  verge  of  insanity,  were  guarded  against  pro- 
nounced insanity  by  the  mental  excitement  and  occupa- 
tion afforded  by  the  troublous  times.  This  question,  how- 
ever, is  very  complicated  in  character. 

There  is  no  doubt  that  the  improvement  in  food,  cloth- 
ing, and  dwellings,  which  goes  hand  in  hand  with 
advancing  civilization,  does  not  favor  the  development  of 
mental  diseases.  The  general  advance  in  moral  ideas 
also    antagonizes  the    spread  of    insanity,  so  that  it  re- 


RACE   AND    NATIONALITY.  23 

mains  doubtful  whether  civilization  in  general  may  be 
regarded  as  the  cause  of  the  increase  in  insanity. 

Race  and  Nationality. 

For  a  time  it  was  believed  that  the  Scotch  Highlanders, 
the  Irish,  and  the  negro,  exhibited  less  tendency  to  in- 
sanity, because  certain  forms,  especially  paralytic  demen- 
tia, were  not  observed  among  them.  This  exceptional 
condition  disappeared  as  soon  as  these  people  began  to 
live  in  the  large  cities.  In  the  United  States  the  negroes 
are  now  attacked  by  general  paresis,  from  which  they  re- 
mained exempt  during  slavery.  Perhaps  the  Jews  exhibit 
a  comparatively  greater  predisposition  to  insanity,  but 
this  may  be  explained  by  another  peculiarity  apart  from 
race,  viz.,  the  fact  that  the  Jews  intermarry  very  often  in 
close  family  circles ;  the  crossing  is  insufficient,  and  hered- 
ity thus  gives  rise,  by  in-breeding,  to  a  rapidly  increasing 
predisposition.  In  general,  however,  statistics  show  no 
special  tendency  of  any  race  to  insanity,  and  this  is  also 
true  of  the  different  nationalities. 

Geographical  Position,  Soil,  Food. 

The  geographical  position  of  a  people  is  sometimes  asso- 
ciated with  mental  diseases.  A  connection  has  always 
been  assumed  between  the  endemic  occurrence  of  cretinism 
in  some  of  the  Alpine  valleys  and  certain  conditions  of  the 
soil.  The  excessive  use  of  maize  as  an  article  of  food  by 
the  peasants  of  Northern  Italy  gives  rise  to  so-called  pel- 
lagrous insanity. 

Seasons  and  Climate. 

The  effect  of  these  cosmical  conditions  cannot  be  ascer- 
tained with  certainty.  A  few  observations  among  agri- 
cultural populations  appear  to  show  that  there  are  more 
admissions  to  lunatic  asylums  during  the  summer  months, 
but  this  also  appears  to  be  true  of  cities.  As  a  general 
thing,  climate  also  exerts  no  influence. 


24  HANDBOOK   OF   INSANITY. 


Sex  and  Social  Position. 

In  men  the  more  efficient  and  dangerous  factors  are  the 
struggle  for  existence,  drunkenness,  and  excesses ;  women 
are  more  endangered  by  pregnancy  and  the  puerperal  con- 
dition, lactation,  or  unsatisfied  sexual  life.  According  to 
the  law  of  crossed  heredity,  and,  at  the  same  time,  the 
predominating  influence  of  the  father,  insanity  will  be 
inherited  somewhat  more  frequently  by  the  female  off- 
spring. Inasmuch  as  periodical  disorders,  as  a  rule,  are 
hereditary,  the  repeated  number  of  admissions  to  asylums 
to  which  this  very  fact  gives  rise  will  in  itself,  appa- 
rently, increase  still  more  the  already  more  frequent  affec- 
tions of  this  kind  in  females.  It  is  a  striking  fact  that 
many  very  young  girls  are  attacked  by  insanity.  This 
must  be  attributed  to  faulty  education,  rather  than  to 
unsatisfied  sexual  desire,  inasmuch  as  so  many  of  the  pa- 
tients have  hardly  entered  upon  the  period  of  puberty. 
In  later  years,  the  evil  effects  of  celibacy  are  more  pro- 
nounced in  women  than  in  men. 

Age. 

We  cannot  speak  of  insanity  of  the  new-born,  because 
in  them  the  manifestations  of  mental  life  consist,  at  the 
most,  of  instinctive  movements,  but  the  germs  of  the  dis- 
ease are  apt  to  develop  at  this  early  age.  The  brain  of 
the  new-born  is  very  susceptible  to  irritation,  despite  its 
ability  rapidly  to  overcome  single  injurious  influences. 
This  is  shown  by  the  marked  rise  of  temperature  follow- 
ing slight  irritants,  but  which  remain  without  permanent 
injury,  if  they  act  only  temporarily.  Nervous  disturbances 
are,  however,  a  frequent  result  of  prolonged  febrile  con- 
ditions. 

The  consideration  of  the  causes  of  insanity  in  childhood 
is  very  important.  The  division  of  the  original  instinc- 
tive life  into  conscious  sensations  and  concepts,  begins  to 
develop  during  childhood.     Volition  and  thought,  apart 


AGE.  25 

from  sensory  impressions,  are  not  yet  present.  Hence, 
we  speak  of  desires  which  grow  from  the  sensual  basis  of 
feelings  of  pleasure  and  dislike.  The  personality,  which 
is  not  yet  completely  defined,  is  passionate  and  instinctive, 
and  unconscious  egoism  is  a  constant  phenomenon.  The 
manifestations  of  this  process  of  development  are  subject 
to  rapid  changes  and  alternations. 

Completely  developed  mental  disorders  are  very  rarely 
found  in  childhood.  Their  form  is  often  so  indefinite  that 
they  are  regarded  rather  as  evidences  of  naughtiness  and 
bad  manners.  Among  the  poorer  classes  there  is  a  de- 
cided predominance  of  idiocy,  and  this  must  be  attributed 
to  insufficient  nourishment. 

Great  importance  attaches  to  the  influence  of  heredity 
in  the  mental  disorders  of  childhood.  Children,  whose 
ancestors  suffered  from  insanity  or  other  nervous  dis- 
eases, not  alone  become  delirious  from  slight  causes,  such 
as  digestive  disturbances,  slight  fever,  teething,  but  they 
are  apt  to  be  depressed  for  a  long  time  after  the  ordinary 
disagreeable  events  of  daily  life.  Mental  work  at  school 
rapidly  exhausts  them ;  fright  and  punishment  excite  them 
in  a  dangerous  degree.  Many  of  these  children  also  ex- 
hibit evidences  of  bodily  degeneration. 

Apart  from  hereditary  influences  the  morbid  predispo- 
sition not  infrequently  develops  from  injuries  sustained 
during  or  after  birth,  such  as  compression  in  a  generally 
contracted  pelvis,  violent  forceps  delivery,  fall  upon  the 
head,  etc.  In  some  of  these  cases  the  physical  develop- 
ment is  delayed.  Such  children  are  especially  apt  to  be 
spoiled  by  the  parents. 

In  the  later  years  of  childhood,  severe  injuries  to  the 
head  are  often  followed  by  imbecility.  The  heat  of  the 
sun,  and  frequent  overheating  of  the  head  by  hot  stoves, 
act  in  the  most  injurious  manner  upon  infants,  and  are 
regarded  as  the  causes  of  early  mental  weakness,  occasion- 
ally of  temporary  conditions  of  excitement.  There  is  no 
doubt  of  the  connection  of  ear  diseases  with  mental  dis- 
orders.     Deaf -mutism  is  a  sad  illustration  of  this  fact. 


26  HANDBOOK   OF   INSANITY. 

All  catarrhs  of  the  ear  in  children  require  the  most  care- 
ful treatment. 

Unbiassed  observers  have  failed  to  note  cases  in  which 
insanity  was  due  to  the  presence  of  worms. 

Among  the  immediate  psychical  causes  I  will  mention 
merely  terror,  fright,  and  worry,  which  lead  occasionally 
to  suicide.  The  importance  of  imitation  will  be  consid- 
ered later. 

The  next  period  at  which  a  distinct  change  develops  in 
the  bodily  and  mental  processes  is  the  age  of  sexual  de- 
velopment or  puberty. 

The  addition  of  the  powerful  sexual  impulse  considera- 
bly enlarges  the  category  of  ideas  at  the  age  of  puberty.  It 
is  a  further  important  fact  that  at  this  period  the  heredi- 
tary predispositions  become  especially  evident.  Physio- 
logical development  gives  a  new  impetus  to  the  inherited 
cells  in  the  germ-layer,  and  thus  the  phenomena  depend- 
ent thereon  appear  almost  suddenly  in  full  intensity. 
For  this  reason  mental  disorders  are  much  more  frequent 
at  the  period  of  puberty  than  during  childhood,  and  they 
are  more  varied  in  character,  in  accordance  with  the  larger 
experience  of  the  individual  at  puberty.  This  period  re- 
tains the  instinctive  manifestations  of  emotional  life, 
and  in  addition  there  are  vague  sexual  feelings  whose  end 
is  indistinctly  recognized,  and  lead  to  perverted  interpre- 
tations and  manifestations.  Fantastic  moods  characterize 
the  common  basis  from  which  mystical  and  sexual  feel- 
ings arise.  Violent  outbreaks,  sudden  actions,  without  a 
real  internal  basis,  arise  in  this  stage  of  development  of 
the  vital  processes.  Rapid  change  of  mood  is  very  char- 
acteristic. Apathy  of  feeling,  and  the  most  superficial 
judgment  of  the  dangerous  results  of  the  instinctive  actions 
indicate  the  almost  always  rapidly  developing  mental  weak- 
ness in  the  cases  in  which  hereditary  predisposition  coin- 
cides with  the  development  of  puberty.  We  must  hold 
fast  to  the  great  frequency  of  hereditary  taint  in  mental 
diseases  of  puberty.  For  this  reason  they  also  exhibit  the 
other  signs  of  hereditary  affections,  viz.,  rapid  improve- 


PUBERTY.  27 

ment,  frequent  relapses,  and  persistence  throughout  almost 
the  entire  life.  If  hereditary  taint  is  wanting,  the  purely 
affective  forms  of  insanity,  which  are  more  favorable  as 
regards  permanent  recovery,  are  more  frequent  than  the 
other  forms. 

At  this  age  we  find  comparatively  many  incendiaries 
who  commit  such  actions  either  from  uncomprehended 
internal  motives,  or  from  impulsive,  but  clearly  defined 
feelings.  Homesickness  is  another  feeling  which  may 
increase  to  a  morbid  height.  Other  conceptions  also  force 
themselves  upon  the  child,  accompanied  only  occasionally 
by  hallucinations.  Peculiar  disturbances  of  motion,  which 
have  an  awkward  and  foolish  character,  must  also  be  re- 
garded as  the  results  of  the  ill-defined  feelings  and  impulses 
to  which  we  have  referred.  Temporary  muscular  rigidity 
is  sometimes  present. 

Certain  of  these  conditions  have  been  grouped  under  the 
term  hebephrenia,  but  it  is  unnecessary  to  increase  still . 
further  the  numerous  forms  of  insanity  by  giving  them 
different  names,    according   to   the   age  at  which   they 
develop. 

At  this  period,  girls  are  exposed  to  greater  risk  of  men- 
tal disorder  than  boys,  but  after  sexual  maturity  is  estab- 
lished the  danger  is  less  for  a  number  of  years,  until  they 
reach  the  age  when  the  requirements  of  life  bring  new 
duties  and  injurious  influences. 

The  period  of  greatest  bodily  and  mental  development 
shows  the  greatest  frequency  in  the  number  of  cases  of 
insanity.  The  mental  equilibrium  is  disturbed  by  external 
circumstances  and  influences,  but  the  internal  vital  condi- 
tions, as  such,  are  more  innocuous.  In  old  age,  on  the 
contrary,  the  internal  processes  do  the  most  harm.  The 
exhausting  influences  of  mature  life  are  the  bodily  and 
mental  excesses,  which  are  brought  on  by  the  stress  of 
life's  battles.  Although  the  power  of  resistance  is  great- 
est, the  harmful  influences  have  grown  to  a  disproportion- 
ate extent.  Among  these,  alcoholism  and  syphilis  need 
special  mention.     Dementia  paralytica  occurs  chiefly  at 


28  HANDBOOK   OF   INSANITY. 

this  age,  apparently  as  the  result  of  the  causes  referred  to, 
and  independently  of  hereditary  taint. 

At  the  age  of  bodily  and  mental  retrogression,  more 
harm  results  from  internal  processes.  Like  the  beginning 
of  the  sexual  functions,  so  also  its  cessation  produces  pro- 
found changes  in  the  entire  personality.  In  women  the 
beginning  of  this  period  (menopause)  is  more  sharply  de- 
fined than  in  men.  Even  in  otherwise  healthy  women, 
striking  mental  changes  are  observed  at  this  period,  and 
there  is  often  a  fuller  mental  development. 

The  close  relationship  of  olfactory  hallucinations  and 
sexual  irritation  is  also  manifested  at  this  period.  If 
malignant  tumors  develop  in  the  breasts  or  ovaries  during 
the  menopause,  coincident  mental  disturbances  are  very 
often  accompanied  by  hallucinations  of  touch  and  smell. 

The  constant  mental  changes  appear  to  belong  among 
the  first  signs  of  the  onset  of  the  change  of  life ;  generally 
a  depressed,  but  occasionally,  a  cheerful  mood.  Artificial 
removal  of  the  ovaries  may  act  in  the  same  way  as  the 
menopause.  Indeed,  this  is  also  observed  after  ovarioto- 
mies, total  extirpations,  or  laparotomies  in  general. 
Perhaps  such  results  are  due  to  the  action  of  the  sympa- 
thetic nervous  system.  Certain  symptoms  of  the  meno- 
pause, such  as  hot  flushes  and  other  congestive  phenomena, 
speak  decidedly  in  favor  of  this  connection. 

In  men  the  period  of  retrogression  is  much  more  pro- 
longed. Growing  old  is  the  sign  of  involution  of  all  the 
vital  processes.  The  activity  of  the  brain  is  impaired  by 
the  internal  processes ;  the  rigidity  and  calcification  of  the 
vessels  play  a  part  in  this  condition.  A  characteristic  of 
the  process  of  involution  is  the  return  of  the  instinctive 
desires  and  impulses,  and  this  indicates  the  recurrence  to 
the  childish  stage.  The  gradual  decay  of  the  nervous 
system  takes  place  in  a  direction  opposite  to  that  in  which 
it  reached  its  highest  development.  Memory  is  the  most 
marked  illustration  of  this  fact.  The  influence  of  heredi- 
tary predisposition  is  also  noticeable  during  the  period  of 
involution.     But  when,  despite  the  gradually  increasing 


HEREDITY.  29 

weakness  of  the  mental  functions,  the  frequency  of  mental 
diseases  diminishes  with  increasing  age,  it  must  be  re- 
membered that  the  number  of  predisposed  individuals  is 
diminished  by  the  fact  that  many  of  them  have  been 
attacked  by  insanity  at  an  earlier  period,  and  that,  as  a 
rule,  the  cares  and  worries  of  life  diminish  in  old  age. 
Apart  from  rapidly  increasing  mental  weakness,  the 
symptoms  of  insanity  in  old  age  often  are  complicated  by 
paralytic  phenomena,  which  are  due  mainly  to  disease  of 
the  vessels. 

Heredity. 

In  investigating  the  question  of  heredity,  we  must  en- 
deavor, if  possible,  to  go  back  several  generations.  Apart 
from  many  other  accidental  causes,  it  must  be  remembered 
that  a  child  is  not  alone  the  offspring  of  his  parents,  but 
is  also  the  last  link  in  a  long  chain  of  ancestors.  It  is 
impossible  that  all  their  peculiarities  can  be  inherited  by 
one  individual.  Certain  members  of  a  family  escape  the 
inheritance  of  various  peculiarities,  for  definite  diseases, 
such  as,  for  example,  haemophilia,  are  propagated  only 
in  the  male  line,  or  they  skip  a  generation.  The  connect- 
ing link  in  the  chain  of  inheritance  of  insanity  may  also 
be  formed  by  other  nervous  diseases  or  by  allied  condi- 
tions, such  as  striking  peculiarities,  criminal  or  suicidal 
tendencies.  As  the  interpretation  of  such  conditions  va- 
ries with  the  personal  view-point,  it  is  clear  that  the 
statistics  concerning  the  importance  of  heredity  will  vary 
greatly.  According  to  cautious  investigators  thirty  to 
forty  per  cent  of  cases  of  insanity  exhibit  evidences  of 
heredita^  taint. 

Numerous  experiences  in  psychiatry  favor  the  notion 
that  even  acquired  peculiarities  may  be  communicated  to 
the  offspring.  The  probability  of  inheritance  is  very 
greatly  increased,  if  both  parents  have  an  hereditary  taint, 
or  suffer  from  insanity.  The  danger  is  much  less  when 
the  predisposition  is  transmitted  only  on  one  side.  It 
must  also  be  remembered  that  acquired  insanity  in  the. 


30  HANDBOOK   OF   INSANITY. 

ancestors  is  only  dangerous  when  children  are  born  during 
the  course  of  the  mental  disorder. 

It  is  now  regarded  as  certain,  that  the  influence  of  the 
father  in  heredity  is  more  important  than  that  of  the 
mother.  Inasmuch  as  inheritance  is  usually  crossed,  we 
should  expect  that  the  female  members  of  the  family  would 
be  more  endangered.  This  is  not  entirely  confirmed  by 
experience,  because,  according  to  several  authorities,  in- 
sanity of  the  mother  is  especially  apt  to  be  inherited 
by  the  daughters.  Hereditary  taint,  when  transmitted 
through  several  generations,  gradually  leads  to  degenera- 
tion. In  the  first  generations  we  find,  apart  from  nervous 
symptoms,  the  disappearance  of  ethical  feelings ;  then  fol- 
lows a  generation  in  which  the  tendency  to  excesses 
appears,  and  the  danger  is  then  greatly  increased  by  alco- 
holism. In  the  third  generation  there  is  perhaps  suicide 
or  an  affective  form  of  insanity,  and  finally  there  appear 
more  profound  mental  disorders,  such  as  congenital  idiocy. 
The  last  stage  is  often  associated  with  various  malforma- 
tions and  inhibitions  of  development. 

As  regards  the  form  of  mental  disturbance,  heredity  acts 
in  two  ways,  each  of  which  is  sharply  defined,  and  only 
rarely  do  we  find  transitional  forms.  The  more  extensive 
group  embraces  symptom-complexes  which  are  distin- 
guished, not  alone  by  variability  as  regards  each  one,  but 
also  by  the  fact  that  they  are  apt  to  pass  into  one  another. 
This  group  has  taught  the  multifarious  relations  of  hered- 
ity; all  the  neuroses  already  mentioned  and  allied  condi- 
tions, such  as  inebriety,  criminal  impulses,  etc.,  lead  to 
the  most  manifold  symptoms  as  the  result  of  hereditj\ 

In  the  second  group  there  is  inheritance  of  the  same 
form  of  mental  disturbance  as  that  presented  by  the  an- 
cestor, but  this  form  is  very  much  rarer  than  the  preceding 
variety.  The  disease  may  appear  in  the  children  at  the 
same  age  as  it  did  in  the  parents,  or  under  similar  condi- 
tions— for  example,  when  mother  and  daughter  are  attacked 
in  childbed.  The  most  striking  phenomenon  in  this  re- 
spect is  the  inheritance  of  the  tendency  to  suicide.     Cases 


HEREDITY.  31 

are  reported  in  which  one  member  of  a  family  after  another 
committed  suicide,  although  they  lived  in  remote  parts  of 
the  world.  Suicide  on  an  hereditary  basis  is  found  even 
in  children  at  the  age  of  five  years. 

As  we  have  already  hinted,  the  variability  of  the  symp- 
toms in  the  individual  case  is  characteristic  of  hereditary 
taint.  Eapid  changes  of  mood,  frequent  relapses,  compar- 
atively great  mental  ability,  are  found  in  addition  to  pro- 
nounced evidences  of  disease.  On  the  other  hand,  there 
is  sometimes  a  striking  uniformity  in  the  course  of  the 
individual  attack  of  insanity  in  certain  cases. 

It  was  formerly  supposed  that  relationship  of  the  parents 
was  sufficient  to  produce  insanity  in  the  offspring.  This 
is  disproved  by  more  recent  statistics  and  by  historical 
illustrations — for  example,  the  Ptolemy s.  Among  them 
the  king  always  married  his  sister,  yet  insanity  was  not 
pronounced  in  this  family  during  a  period  of  three  hun- 
dred years.  Nevertheless,  it  remains  an  interesting  fact 
that  deaf -mutism  often  occurs  as  the  result  of  intermarriage 
of  relations. 

The  condition  of  the  parents  at  the  moment  of  impreg- 
nation is  also  important.  Children  procreated  during  the 
drunkenness  of  otherwise  healthy  parents  sometimes  ex- 
hibit congenital  mental  and  nervous  disturbances.  The 
significance  of  morbid  cerebral  activity  at  the  moment  of 
procreation  is  also  shown  by  the  fact  that  insane  individ- 
uals produced  healthy  children  during  the  intervals 
between  attacks  of  insanity. 

The  assumption  that  heredity  depends  upon  a  definite 
condition  of  the  germ-layers  is  favored  by  the  observa- 
tion that,  in  cases  of  hereditary  taint,  the  outbreak  of  the 
disease  very  often  occurs  at  the  period  of  puberty.  The 
general  change  in  all  the  internal  vital  processes  at  this 
period  makes  it  easily  understood  that  such  germ-layers 
should  also  be  implicated. 


32  HANDBOOK   OF   INSANITY. 

Crime  and  Genius. 

There  is  no  doubt  that  a  considerable  number  of  crimes 
are  committed  by  the  insane,  and  it  has  been  proven  that 
the  greatest  criminals  belong,  as  a  rule,  to  families  in 
which  hereditary  taint  has  been  demonstrated.  Further- 
more, the  offspring  of  such  criminals  are  often  attacked 
by  insanity. 

The  Italian  school  has  made  extensive  investigations  in 
this  direction.  In  addition  to  the  proof  that  a  number  of 
criminals  resemble  savages  (among  other  resemblances, 
tattooing  is  especially  frequent  among  them) ,  it  has  been 
shown  that  the  born  criminal  resembles  the  insane  or  epi- 
leptic. Changes  in  the  skull  and  brain  and  imperfect 
development  of  ethical  feelings  have  been  found.  Other 
characteristics  common  to  both  groups  are  the  frequent 
relapses,  independent  of  good  or  bad  treatment,  good  or 
bad  external  surroundings. 

Genius  has  also  been  said,  by  some  writers,  to  be  con- 
nected with  insanity.  It  is,  indeed,  an  astonishing  fact 
that  many  men  of  great  talents  belong  to  families  with  an 
hereditary  taint,  that  many  become  insane,  or  have  feeble- 
minded brothers  and  sisters  or  children.  Finally,  it  has 
often  been  observed  that  a  family  unexpectedly  dies  out 
in  the  person  of  a  great  genius.  All  these  phenomena  are 
characteristic  of  hereditary  conditions,  but  the  question  is 
not  yet  thoroughly  settled. 

Education. 

One  of  the  purposes  of  an  ideal  education  is  the  removal, 
by  means  of  the  uniform  development  of  all  the  functions 
of  body  and  mind,  of  those  dangers  which  may  leadr  to 
insanity.  The  present  neglect  of  physical  education  in- 
creases still  further  the  efficiency  of  the  errors  in  mental 
education.  Errors  in  education  are  most  dangerous  when 
they  coincide  with  hereditary  predisposition.  Excessive 
strictness  as  well  as  latitude  may  work  equal  mischief. 
The  passions  and  desires  of  the  children  must  be  regulated 


OCCUPATION.  33 

so  that  they  do  not  forget  the  habit  of  self-control.  A 
strain  upon  the  memory  as  the  result  of  learning  by  rote 
may  produce  precocious  children,  but  they  fail  when  sub- 
jected to  the  strain  of  actual  life.  Children  in  general 
attend  school  at  too  early  a  period,  and  are  compelled  to 
study  too  long  and  often  under  unfavorable  hygienic  con- 
ditions. 

Occupation. 

Brain-workers  are  more  endangered  than  those  who  do 
manual  labor.  Among  the  former  artists  occupy  the  front 
rank  as  regards  the  danger  of  insanity.  Even  under  or- 
dinary circumstances,  constant  devotion  to  music  is  very 
wearing.  Nervous  conditions  of  all  kinds,  especially  in- 
somnia, are  rapidly  produced;  irritability  in  family  life 
is  apt  to  davelop.  Actors  rank  next  to  artists  in  this  re- 
spect. The  excitement  of  speculation  is  also  injurious, 
and  many  merchants  succumb  to  paralytic  dementia. 
During  a  war,  soldiers  are  also  exposed  to  many  causes 
of  insanity — forced  marches,  exhausting  diseases  and 
wounds,  and  excitement  of  all  kinds. 

The  causes  of  the  frequent  affection  of  prostitutes,  sail- 
ors, and  others  in  the  lower  walks  of  life,  are  complicated 
in  character.  They  include  drink,  poverty,  syphilis,  and 
sexual  excesses.  Many  prostitutes  have  an  hereditary 
taint. 

The  absence  of  an  occupation  is  also  an  efficient  factor, 
as  is  illustrated  by  the  frequency  of  insanity  among 
tramps. 

Insanity  also  occurs  frequently  among  prisoners;  prom- 
inent causes  are  remorse,  and  solitary  confinement,  which 
favors  the  sudden  development  of  terrifying  hallucinations. 

B.    CAUSES   WHICH   ACT   ONLY   ON   THE   INDIVIDUAL. 

BODILY  CAUSES. 

The  Brain  and  Its  Membranes. 
Almost  all  diseases  influence  the  mood  to  a  certain  ex- 
tent.    We  need  merely  mention  the  depression  of  gastric 


34  HANDBOOK   OF   INSANITY. 

and  intestinal  affections,  the  anxious  conditions  in  circu- 
latory disturbances,  the  peculiar  cheerful  and  careless 
mood  of  some  phthisical  patients.  The  more  directly  such 
influences  act  upon  the  cerebral  cortex,  the  more  dangerous 
do  they  become. 

Among  the  influences  which  exert  a  material  influence 
on  mental  disorders  is  congestion  of  the  cerebral  cortex. 
This  acts  either  by  increasing  the  cerebral  pressure,  or  by 
gradually  changing  the  nutrition  of  the  tissues. 

Mental  disturbance  does  not  always  follow  congestion, 
because  relief  is  long  possible  on  account  of  the  extensive 
vascular  network  of  the  cortex.  If  this  does  not  occur, 
insomnia  is  the  most  common  result ;  restlessness,  irrita- 
bility, and  hallucinations  are  also  frequent  symptoms. 
Insolation  is  a  cause  of  such  congestion,  and  the  latter  also 
accompanies  various  cerebral  and  meningeal  diseases. 
This  is  easily  explained  by  the  anatomical  association  of 
the  blood-vessels  of  the  meninges  and  cortex.  The  diffuse 
changes  thus  produced  in  the  cerebral  tissues  are  impor- 
tant, but  similar  symptom-complexes  may  also  be  produced 
by  focal  lesions,  if  they  develop  in  the  cortex  and  are  at- 
tended with  diffuse  changes  in  their  vicinity.  A  deficiency 
of  blood  or  venous  stasis,  even  if  it  develops  suddenly 
from  paralysis  of  the  vasomotor  nerves,  diminishes  the 
irritability.  One  of  the  most  striking  symptoms  of  cor- 
tical anaemia  is  drowsiness ;  this  may  terminate  in  stupor 
and  unconsciousness,  sometimes  combined  with  convul- 
sions, if  the  anaemia  develops  rapidly.  Its  slower  develop- 
ment leads  to  impairment  of  memory  and,  indeed,  of  the 
mental  functions  in  general.  In  most  diseases  of  the  brain 
and  meninges,  the  change  of  symptoms  is  frequent,  on  ac- 
count of  the  numeraus  changes  in  the  degree  of  fulness  of 
the  cerebral  vessels. 

Everjr  form  of  meningitis  may  lead  to  mental  disturb- 
ance. Hemorrhage,  softening,  multiple  and  general  scle- 
rosis, gliosis  and  tumors,  if  they  give  rise  to  diffuse 
changes  in  the  vicinity,  are  generally  followed  by  condi- 
tions of  mental  enfeeblement. 


INJURIES   TO   THE   HEAD.  35 

Cerebral  concussion  and  injuries  to  the  head  give  rise 
to  inflammations  of  the  skull  and  meninges,  which  may 
extend  to  the  brain.  In  the  brain  itself  they  may  cause 
disturbances  of  the  cortical  circulation,  with  secondarj^ 
nutritive  disturbances  and  psychical  disease.  The  latter 
either  follows  the  injury  at  once,  or  appears  after  a  long 
interval.  When  cerebral  concussion  leads  at  once  to  dis- 
ease, there  are  found,  in  addition  to  headache,  vertigo  and 
terrifying  hallucinations,  sensory  and  motor  disturbances, 
such  as  narrowing  of  the  pupils,  gritting  of  the  teeth,  and 
paralyses.  These  symptoms  generally  subside  quite  rap- 
idly, but  indecision  and  enfeebled  mental  activity,  with 
great  irritability,  persist  for  a  longer  time.  In  many 
cases  the  further  course  is  very  unfavorable,  and  permanent 
mental  weakness  sets  in.  The  slowly  developing  cases 
also  exhibit  irritability  and  weakness  from  the  start;  epi- 
leptic convulsions,  without  any  demonstrable  local  lesion, 
have  also  been  observed.  Such  persons  are  easily  ex- 
hausted, and  this  is  also  shown,  for  example,  by  the  slight 
power  of  resistance  to  small  doses  of  alcohol.  Although 
it  cannot  be  denied  that  the  majority  of  mental  disorders 
after  injury  are  characterized  by  great  irritability,  inde- 
cision, and  rapid  mental  enfeeblement,  yet  the  term  trau- 
matic insanity  is  a  generic  term,  which  embraces  the 
most  varied  causes  and  symptoms. 

Coincident  Diseases   of  the  Cord,  Nerves  and  Sym- 
pathetic. 

There  is  sometimes  a  hardly  noticeable  transition  in  the 
occurrence  of  the  symptoms  when  the  causes  develop  at 
the  same  time  in  the  brain  and  spinal  cord.  We  need 
merely  call  to  mind  the  diffuse  and  systematic  scleroses  of 
the  cerebral  nervous  system,  and  especially  tabes.  The 
clinical  symptoms  of  the  latter  are  sometimes  united  so 
closely  with  those  of  paralytic  dementia  that  they  are 
inseparable.  On  the  other  hand,  tabes  may  occur  inde- 
pendent^ in  connection  with  a  mental  disorder,  so  that 
their  relation  is  not  certain.     But  there  are  certain  signs, 


36  HANDBOOK   OF   INSANITY. 

especially  persecutory  delirium  with  hallucinations,  whose 
constant  associated  occurrence  forces  us  to  the  conclusion 
that  the  tabes  and  psychosis  have  a  common  basis.  Mental 
weakness  often  develops,  especially  at  the  close  of  the 
course  of  tabes.  The  recent  interpretation  of  tabes  as  a 
disease  of  the  entire  cerebral  nervous  system,  assumes  a 
direct  connection  between  the  tissue  changes  in  the  brain 
and  cord. 

The  medium  of  the  vasomotor  system  becomes  necessary 
in  explanation  of  the  mental  disturbances  in  general  neu- 
roses, neuralgias,  and  injuries  to  the  nerves.  Mild  dis- 
turbances, especially  depression,  are  sometimes  found  in 
Basedow's  disease.  Insanity  also  accompanies  chorea  not 
infrequently.  The  symptoms  are  terror,  loss  of  memory, 
and  irritability.  Epilepsy  and  hysteria  are  also  often 
associated  with  insanity,  but  these  affections  will  require 
special  consideration. 

The  vasomotor  element  is  still  more  distinct  in  certain 
neuralgias ;  the  connection  is  especially  distinct  when  the 
attacks  of  pain  periodically  precede  the  mental  disturb- 
ance, or  the  latter  follows  pressure  on  painful  points  along 
the  nerves.  Temporary  conditions  of  excitement  have  also 
occurred  after  operations  of  various  kinds,  during  which 
sensitive  nerves  have  been  injured. 

Affections  of  the  cutaneous  nerves  may  induce  morbid 
mental  symptoms.  Even  slight  cutaneous  eruptions  give 
rise  to  irritability  and  bad  temper,  and  in  predisposed 
individuals  they  may  cause  an  outbreak  of  insanity  or 
color  its  symptomatology.  Disease  of  the  terminal  rami- 
fications of  the  nerves  of  special  sense  may  also  provoke 
hallucinations  and  mental  disturbance,  but  as  a  rule  hal- 
lucinations are  central  in  origin. 

Anaemia  and  Exhausting  Diseases  of  Internal  Organs. 

The  following  causes  act  as  remote  causes  of  insanity, 
not  alone  by  vasomotor  or  reflex  influences,  but  also,  as  a 
rule,  through  the  agency  of  a  general,  prolonged  anaemia. 
These  include  pulmonary  diseases  of  all  kinds,  but  the 


VISCERAL   DISEASES.  37 

causal  significance  of  tuberculosis  is  not  very  great.  The 
importance  of  heart  disease  as  a  cause  of  insanity,  in  so 
far  as  the  connection  is  explained  by  the  general  anaemia, 
is  also  greatly  overestimated.  In  some  cardiac  affections 
there  is  passive  congestion  of  the  brain ;  in  these  there  are 
apt  to  be  conditions  of  anxious  excitement,  while  depres- 
sion predominates  in  general  weakness  of  the  circulation 
and  anaemia.  The  reflex  effects  of  palpitation  and  cardiac 
oppression  also  attend  these  diseases.  All  cardiac  patients 
are  irritable ;  in  coincident  insanity  the  peculiar  restless- 
ness is  often  manifested  impulsively  in  violence.  Aortic 
lesions,  however,  are  usually  an  exception  to  this  rule. 

The  development  of  imbecility  after  operative  removal 
of  the  thyroid  gland  is  a  noticeable  phenomenon;  it  is 
supposed  to  result  from  changed  circulatory  conditions  in 
the  brain. 

Importance  has  always  been  attached  to  digestive  dis- 
turbances as  a  cause  of  insanity.  The  abundant  nerve 
plexuses  of  the  abdomen  are  a  source  of  reflex  irritation. 
The  possibility  of  the  absorption  of  toxic  substances,  for 
example  sulphuretted  hydrogen,  has  also  been  kept  in 
mind.  Irregular  distribution  of  blood,  stases  in  the  portal 
circulation,  undoubtedly  play  a  certain  part.  The  chief 
importance,  however,  attaches  to  the  impairment  of  general 
nutrition,  but  we  must  avoid  mistaking  cause  and  effect, 
inasmuch  as  digestive  disturbances  often  result  from  the 
psychical  disease.  Psychoses  due  to  intestinal  worms  are 
found,  perhaps,  only  in  children. 

Psychical  disturbances  in  the  course  of  renal  disease 
must  be  attributed  to  acute  or  chronic  uraemia.  In  Eng- 
land, however,  it  is  maintained  that  both  diseases  are  due 
to  vascular  changes. 

Diseases  of  the  Sexual   Organs  and  Disturbances  of 
Their  Function. 

Some  observers  regard  this  cause  as  very  frequent  in 
females,  others  think  it  very  unimportant,  but  all  are 
agreed  that  diseases  of  the  male  sexual  organs  play  a  very 


38  HANDBOOK   OF   INSANITY. 

minor  part.  In  women  tissue  changes  and  displacements 
of  the  uterus,  with  inflammatory  conditions,  are  impor- 
tant. Although  they  do  not  often  produce  decided  insan- 
ity, nervous  disturbances  are  usually  not  wanting.  Vag- 
inal catarrhs,  ulceration  of  the  cervix,  neoplasms,  etc.,  act 
in  this  way.  An  erotic  or  hysterical  character  is  often 
absent.  The  sterility  due  to  genital  affections  often  acts 
in  a  psychical  manner.  The  disturbances  of  menstruation 
must  be  regarded  both  as  cause  and  effect.  Although  it 
is  doubtful  whether  they  often  produce  insanity,  they  often 
influence  the  course  of  the  mental  diseases. 

Sexual  excesses  may  undoubtedly  produce  psychoses, 
but  they  are  also  often  an  indication  of  already  existing 
disease.  The  principal  injurious  factor  is  the  exhausting 
nervous  action,  and  for  this  reason  unnatural  gratification 
of  sexual  desire  is  the  most  dangerous.  In  some  cases 
masturbation  results  from  peripheral  irritation,  such  as 
oxyuri  and  cutaneous  eruptions  near  the  genitalia,  but 
in  the  majority  of  cases  the  cause  is  cerebral.  In  these 
patients  are  often  found,  due  to  the  same  cerebral  basis, 
olfactory  hallucinations  of  a  disagreeable  character,  such 
as  the  stench  of  faeces  and  corpses ;  these  phenomena  are 
associated  not  infrequently  with  a  tendency  to  religious 
mysticism. 

It  is  often  maintained,  particularly  with  regard  to 
women,  that  continence  produces  a  predisposition  to  men- 
tal disorders.  This  is  not  true  of  healthy  individuals.  A 
large  number  of  women  never  have  sexual  intercourse  and 
remain  sane.  Those  in  whom  this  cause  is  effective 
probably  suffer  from  an  hereditary  taint. 

The  connection  between  pregnancy  and  insanity  is 
brought  about,  in  part,  by  circulatory  disturbances.  In  ad- 
dition, there  are  chemical  changes  in  the  constitution  of  the 
blood.  It  has  been  held,  in  opposition  to  this  view,  that 
the  mental  disturbance  sometimes  continues  after  delivery, 
but  experience  teaches  that  this  is  not  true  in  many  cases. 
In  combination  with  other  causes,  for  example,  heredity, 
the  frequent  occurrence  of  psychoses  during  pregnancy  is 


PREGNANCY.  39 

easily  understood.  During  the  first  months  of  pregnancy, 
in  which  the  mechanical  changes  in  the  circulation  can 
exert  no  noticeable  effect,  temporary  psychical  disturbances 
of  a  mild  character  may  also  occur.  They  are  probably  the 
result  of  a  reflex  nervous  process.  The  fact  that  women 
who  are  illegitimately  pregnant  are  attacked  most  fre- 
quently, is  due  to  the  numerous  other  harmful  factors  to 
which  they  are  exposed. 

The  connection  between  childbed  and  insanity  is  more 
difficult  of  explanation.  This  fact  is  the  more  striking 
because  certain  symptoms  are  found  quite  constantly  in 
the  puerperal  psychoses.  They  generally  develop  unex- 
pectedly between  the  fifth  and  tenth  days  of  childbed. 
In  some  cases  an  injurious  influence  may  be  exerted  by 
the  prolonged  absorption  of  toxic  substances,  particularly 
when  febrile  movement  has  been  present.  Another  very 
probable  cause  is  the  general  anaemia  which  attends  the 
loss  of  blood.  In  very  rare  cases  conditions  of  violent 
excitement,  lasting  only  a  few  hours,  develop  during  the 
first  few  days  after  delivery,  and  these  must  be  attributed 
to  the  sudden  changes  in  the  circulation  and  to  high  fever. 
Allied  to  these  conditions  is  the  quite  rare  occurrence  of 
insanity  after  miscarriages. 

The  cases  of  insanity  during  lactation  usually  do  not 
develop  before  the  third  month,  and  this  indicates  their 
connection  with  the  general  exhaustion  and  anaemia. 
Hereditary  predisposition  to  mental  disorders  cannot  al- 
ways be  excluded,  and  then  the  lactation  is  merely  an 
exciting  cause  of  the  outbreak  of  insanity. 

Febrile  Diseases  and  Poisoning. 

Formerly  it  was  generally  believed  that  febrile  delirium 
appeared  and  disappeared  with  the  febrile  movement.  It 
must,  therefore,  be  regarded  as  a  step  in  advance,  when  it 
was  learned  that  the  delirium  and  other  mental  disorders  of 
febrile  diseases  may  occur  during  the  prodromal  stage,  prior 
to  the  rise  of  temperature.  On  the  other  hand,  the  mental 
disturbance  may  not  develop  until  the  fever  has  run  its 


40  HANDBOOK   OF   INSANITY. 

course.  Hence  it  follows  that  the  fever  is  not  the  sole 
cause  of  such  symptoms.  Certain  attacks  of  mental  dis- 
turbance may  develop  during  the  course  of  intermittent 
fever,  and  take  the  place  of  the  chill,  although  they  run 
an  apyrexial  course.  The  majority  of  the  diseases  in 
question  are  infectious,  and  their  organized  germs  must 
be  considered  in  connection  with  the  cause  of  the  mental 
disturbances.  This  group  includes  typhoid  and  intermit- 
tent fever,  cholera,  the  acute  exanthemata,  articular  rheu- 
matism, lyssa,  and  perhaps  pneumonia.  It  may  be  assumed 
that  the  germs  of  these  diseases  produce  changes  in  the 
blood,  which  impair  the  nutrition  of  the  cerebral  cortex. 
As  the  virus  is  circulating  in  the  blood  before  the  onset  of 
fever,  we  are  justified  in  assuming  that  this  virus,  not  the 
febrile  movement,  may  give  rise  to  the  mental  disturbance. 
This  also  holds  good  with  regard  to  the  development  of 
symptoms  after  the  cessation  of  the  fever.  The  virus  may 
exert  a  chemical  action,  or  it  may  give  rise  to  local  ana- 
tomical changes  in  the  brain.  In  acute  articular  rheuma- 
tism localized  inflammations  and  mechanical  obstructions 
of  the  vessels  are  found  in  the  meninges  and  the  vessels  of 
the  cortex.  In  view  of  these  facts,  it  is  evident  that  fe- 
brile movement  may  not  be  regarded  as  the  main  cause  of 
these  psychoses,  although  it  undoubtedly  facilitates  their 
outbreak.  The  increase  in  the  bodily  temperature  acts  as 
an  irritant  upon  the  nervous  tissues,  as  is  shown  in  cases 
of  insolation.  If  the  fever t  lasts  a  long  time,  anaemia  of 
the  cortex  results  from  weakening  of  the  heart's  action ; 
when  the  fever  is  of  short  duration,  we  may  assume  con- 
gestion of  the  brain. 

We  will  now  pass  to  the  general  consideration  of  the 
symptoms  which  develop  after  poisoning  by  various  well- 
known  drugs.  There  is  an  entire  series  of  substances 
which  are  taken  for  the  purpose  of  producing  conditions 
like  that  of  drunkenness,  and  whose  continued  ingestion 
leads  to  mental  degeneration  and  disease.  The  extensive 
use  of  opium,  hasheesh,  and  similar  drugs  for  the  produc- 
tion of    intoxication  is  well  known.      Alcohol   may  be 


ALCOHOLISM.  41 

placed  on  a  par  with  opium  as  regards  its  disastrous 
effects.  Its  continued  abuse  gives  rise  to  symptoms 
among  which  mental  weakness  and  moral  deterioration 
are  especially  prominent.  Heredity  also  plays  a  great 
part  in  this  vice,  and  the  psychical  disorder  is  then  apt  to 
be  periodical.  In  such  cases  it  is  sometimes  doubtful 
whether  the  abuse  of  alcohol  is  the  cause  or  effect  of  the 
nervous  predisposition.  Some  patients  experience,  from 
time  to  time,  an  uncontrollable  desire  to  drink.  The 
presence  of  the  alcohol  in  the  drink  is  not,  however,  ab- 
solutely indispensable,  Because  these  individuals,  in  asv- 
lums,  sometimes  drink  only  large  amounts  of  water.  The 
other  causes  which  aid  the  poisonous  action  of  alcohol 
can  only  be  hinted  at ;  the  chief  one  is  the  mental  struggle 
against  the  vice.  The  necessary  degradation  of  the  exter- 
nal surroundings  finally  leads  to  the  overthrow  of  the 
mental  and  physical  forces.  The  poorer  the  quality  of  the 
alcoholic  drink,  the  more  disastrous  are  its  effects ;  whis- 
key which  contains  fusel  oil  and  absinthe  is  much  more 
dangerous  than  beer  and  good  wine. 

Among  physicians  it  is  especially  the  abuse  of  morphine, 
more  rarely  of  cocaine,  which  may  lead  to  the  production 
of  mental  disorders.  The  physician's  ability  to  take  the 
poison  unnoticed  for  a  long  time  is  a  source  of  great 
danger. 

We  will  merely  mention  the  names  of  an  entire  series 
of  substances  which  act  in  a  similar  manner.  Among 
these  are  salicylic  acid,  iodoform,  and  ergot.  After  the 
ingestion  of  the  latter  epidemics  of  psychical  disturbance 
have  been  observed.  Spoiled  maize  has  given  rise  to  wide- 
spread, so-called  pellagrous  insanity.  Psychoses  have 
also  been  observed  after  the  excessive  use  of  tobacco,  also 
after  prolonged  abuse  of  chloroform  and  chloral.  More 
common  are  the  injurious  results  of  poisoning  by  certain 
metals,  especially  lead  and  mercury.  They  occur  not  very 
rarely  in  painters  and  miners  in  lead  works,  either  as 
temporary  conditions  of  violent  excitement,  or  as  pro- 
longed affections,   in  which  disturbances  of  speech  and 


42  HANDBOOK   OF   INSANITY. 

other  paralyses  indicate  pronounced  disease  of  the  cerebral 
cortex.  Workers  in  mercury  also  exhibit  symptoms 
which  indicate  an  action  upon  the  cortex.  The  bromide 
salts  may  give  rise  to  serious  motor  symptoms,  with  men- 
tal enfeeblement,  but  this  usually  disappears  soon  after 
the  discontinuance  of  the  remedy.  Gases  may  act  in  a 
somewhat  similar  manner.  Carbonic  oxide  produces  con- 
gestion of  the  brain,  and  sometimes  even  softening  of  the 
cortex.  Psychical  disorders  have  also  been  reported,  in  a 
few  cases,  after  inhalation  of  carbon  bisulphide  and  also 
illuminating  gas  and  sulphuretted  hydrogen. 

PSYCHICAL    CAUSES. 

The  views  concerning  the  extent  of  efficiency  of  the 
psychical  causes  of  insanity  vary  greatly,  but  I  am  in- 
clined to  believe  that  they  are  among  its  most  frequent 
and  fruitful  sources,  both  in  preparing  the  soil  and 
particularly  in  acting  as  the  immediate  causes  of  the 
disease.  One  cause,  which  acts  as  a  constantly  re- 
peated injury,  is  the  grief  due  to  the  loss  of  near  rela- 
tives. The  effects  of  psychical  pain  are  so  much  more 
marked  when  it  is  kept  hidden  from  view.  The  internal 
wounds,  which  are  concealed  externally  by  smiles,  act 
slowly,  but  surely.  Morbid  general  sensations  increase  the 
emotional  excitement;  insomnia,  in  particular,  prevents 
the  restoration  of  new  force  to  carry  on  the  struggle  in  the 
soul.  There  is  no  doubt  that,  in  numberless  cases,  re- 
pressed or  immoderate  grief  is  the  source  from  which  all  the 
manifestations  of  insanity  flow.  A  similar  effect  is  pro- 
duced by  business  worries.  Their  action  is  slowly  pro- 
gressive; slight  cares  and  troubles  usually  mark  the  onset, 
nor  do  they  need  to  increase  during  the  further  course  of 
the  affection,  inasmuch  as  the  power  of  resistance  dimin- 
ishes under  the  repeated  blows.  Constantly  gnawing  fears, 
without  actual  material  losses,  may  lead  to  the  mental 
breakdown.  We  always  find  two  factors  in  these  causes, 
viz.,  the  repeated  and  constant  occurrence,  and  the  pain- 
ful element  of  feeling.     Both  together  prevent  the  inhibi- 


WORRY    AND    OVERWORK.  43 

tory  counter-effects  of  other  ideas.  Hence,  we  must 
look  upon  continued  painful  feelings  as  the  most  impor- 
tant psychical  causes  of  insanity.  Joyful  feelings  never, 
perhaps,  give  rise  to  insanity,  especially  because,  as  a 
rule,  they  only  act  temporarily  and  the  equilibrium  is 
rapidly  restored. 

The  form  of  the  disease  sometimes  agrees  with  the  de- 
termining cause,  inasmuch  as  fear  and  despair  etc.,  may 
lead  to  similar  notions  during  the  psychosis.  More 
frequently,  however,  the  mental  disturbance  pursues  an 
independent  development,  irrespective  of  the  causal  feeling. 

The  direct  action  of  these  causes  is  rarely  immediate  in 
point  of  time,  as  a  long-continued  internal  psychological 
preparation  is  usually  necessary.  Irritative  and  paralytic 
conditions  of  the  vasomotor  system  are  constantly  noticed ; 
but  it  does  not  explain  very  much  to  say  that  such  condi- 
tions give  rise  to  the  final  symptoms. 

Violent  grief  over  the  loss  of  a  loved  one  is  dissolved  into 
distress  which  lasts  so  much  longer  the  greater  the  gap  that 
has  been  left  in  our  lives.  If  no  restorative  comes  to  the 
exhausted  brain,  torturing  thoughts  stream  rapidly  into 
the  field  of  consciousness,  until  associated  ideas  wTell  up  ir- 
regularly from  the  depths  of  unconscious  cerebral  life,  and 
make  all  order  impossible.  Hence  the  resemblance  of  im- 
moderate emotions  to  maniacal  excitement,  and  also  the 
tendency  of  many  insane  to  unbridled  emotions.  The 
emotional  movement  wells  up  irregularly  from  the  flood 
of  cerebral  activity,  and  volition  can  no  longer  keep  it  in 
the  proper  connection  of  psycho-physical  action.  Voli- 
tional thought  yields  to  the  power  of  external  actions, 
and  the  emotional  excitement  becomes  a  permanent  mor- 
bid disturbance. 

Mental  overwork,  such  as,  for  example,  is  due  to  ambi- 
tion, also  constitutes  a  psychical  cause  of  insanity.  Dis- 
agreeable feelings  here  accompany  failure,  and  disap- 
pointed ambition  is  accompanied  by  inhibited  self-esteem. 
Repeated  failures  and  unavailing  efforts  to  maintain  an 
unduly  exalted  position  increase  these  harmful  influences. 


44  HANDBOOK   OF   INSANITY. 

Unbounded  ambition  may  lead  to  mental  disorder,  but  it 
may  also  be  an  evidence  of  its  actual  existence. 

One-sided  devotion  to  a  few  branches  of  knowledge  also 
acts  injuriously.  Exhaustion  is  here  recognized  by  the 
feeling  of  strain  while  thinking,  and  failure  of  the  associ- 
ation of  ideas ;  these  intellectual  feelings  find  a  place  in 
consciousness,  in  which  only  loose  connections  bind  them 
to  the  bodily  functions,  and  the  connection  with  the  latter  is 
only  established  by  the  introduction  of  bodily  disturbances. 
But  we  are  so  much  the  more  forced  to  regard  these  causes 
of  psychical  disorder  as  direct  and  immediate,  because  the 
efficient  factor  is  the  internal  process  which  runs  its  course 
in  consciousness. 

I  will  briefly  refer  to  two  other  undoubted  direct  causes 
of  insanity.  Unrequited  love  causes  disappointment, 
grief,  and  a  variety  of  violent  feelings,  which  may  exert 
a  profound  influence  on  consciousness,  but  experience 
teaches  that  this  hardly  ever  produces  permanent  mental 
disturbance,  except  upon  an  hereditary  basis.  We  may 
also  refer  to  the  effects  of  religious  sentimentality  upon 
the  production  of  insanity,  merely  to  warn  against  an 
exaggerated  idea  of  its  importance. 

The  occasional  occurrence  of  psychical  epidemics  due  to 
religious  causes  requires  a  few  words  of  comment.  The 
fact  that  morbid  conceptions  may  be  conveyed  to  others 
has  been  observed  in  those  who  lead  secluded  lives,  and 
also  among  large  masses  of  men.  This  has  been  compared 
to  the  process  of  suggestion  during  hypnosis,  and  the  phe- 
nomena in  question  have  been  explained  by  a  sort  of  wak- 
ing suggestion.  A  restriction  of  consciousness  to  a  few 
categories  of  ideas  prevents  the  will  from  rationally  di- 
recting the  course  of  such  ideas.  With  the  increasing 
weakness  of  volitional  activity,  the  combinations  of 
thoughts  which  arise  from  internal  and  external  impres- 
sions assume  the  upper  hand,  and  produce  the  mental 
disturbance. 


III. 

THE   SIGNS   OF   MENTAL   DISORDERS. 

Introduction. 

The  general  doctrine  of  the  signs  of  mental  diseases 
concerns  itself  with  the  elementary  phenomena,  which 
compose  the  most  complex  clinical  pictures.  It  considers, 
from  a  general  standpoint,  the  individual  elementary  dis- 
orders which  are  variously  grouped  in  the  special  forms 
of  disease.  In  order  to  avoid  all  metaphysical  specula- 
tions, we  will  call  the  soul  the  logical  subject,  to  which 
all  the  individual  data  of  internal  experience  and  observa- 
tion are  applied  as  predicates.  We  will  regard  conscious- 
ness as  a  fact  of  experience  of  the  individual,  which  can- 
not be  made  clearer  by  further  definition.  There  is  an 
essential  difference  between  internal  and  external  experi- 
ence, between  the  perception  of  conditions  of  the  ego  and  of 
changes  in  the  external  world.  The  psychical  processes 
in  the  individual  belong  entirely  to  his  inner  experience, 
and  can  only  be  observed  by  others  by  means  of  definite 
changes  in  speech,  gestures,  and  actions.  Hence,  the  phe- 
nomena of  healthy  and  morbid  mental  life  must  be  recog- 
nized  by  the  aid  of  psychology  and  anatomy. 

All  internal  experience  possesses  for  us  direct  reality, 
while  the  objects  of  external  experience  are  only  recog- 
nized indirectly.  If  they  are  to  become  objects  of  con- 
ception and  thought,  they  must  pass  in  some  way  into 
internal  experience.  Concepts,  feelings  and  volitions  con- 
stitute the  contents  of  our  internal  experience,  but  they 
are  so  complex  that  it  becomes  the  object  of  psychology  to 
resolve  them  into  their  simplest  elements.  The  real  ele- 
ment of  all  mental  activities  is  the  impulse,  that  activity 
in  which  sensation  and  will  become  efficient  ,in  their  pri- 

45 


46  HANDBOOK   OF   INSANITY. 

mary  combination.  The  mental  development  of  every 
individual  introduces  herein  the  process  of  apperception, 
i.e.,  the  grasping  of  external  and  internal  impressions  by 
means  of  attention.  It  is  only  with  the  independence  of 
this  process  that  a  higher  mental  development  follows, 
with  which  all  higher  feelings  and  volitions  are  asso- 
ciated. As  these  concepts  are  only  grasped  singly,  their 
grouping  under  general  notions  would  not  aid  us  much 
in  their  comprehension,  but  they  are  so  complicated  that, 
for  clinical  purposes,  they  must  be  divided  into  certain 
groups. 

The  first  group  of  mental  changes  which  we  will  con- 
sider includes : 

A.    THE   DISTURBANCES    OF   CONSCIOUSNESS. 

1.  Disturbances  of  the  Perceptive  Process. 

The  reception  of  sensory  impressions  may  be  disturbed 
in  their  passage  through  the  nerves  of  sense.  This  per- 
ception is  often  falsified  at  the  terminal  distributions  of 
these  nerves.  Diseases  of  the  eye,  catarrhs  of  the  middle 
ear,  irritative  conditions  of  the  nasal  mucous  membrane 
and  the  buccal  cavity,  inflammations  of  the  skin  and  mu- 
cous membranes,  and  morbid  changes  in  the  viscera  and 
muscles,  may  play  a  part. 

Special  attention  must  be  devoted  to  the  eye.  For  the 
present,  we  will  examine  only  the  phenomena  which 
take  place  in  the  terminal  distribution  of  the  optic  nerve. 
This  category  includes  certain  light  phenomena  which 
develop  in  the  retina — the  so-called  light  dust  of  the  inter- 
nal field  of  vision,  also  obscurations  and  color  phenomena. 
Their  development  is  aided  by  processes  in  the  retinal 
vessels,  especially  by  the  implication  of  the  blood  corpus- 
cles. The  pulsation  of  the  central  artery  of  the  retina 
also  produces  hallucinations.  A  material  influence  upon 
these  phenomena  is  exerted  by  the  pupillary  region,  be- 
cause this  is  the  apparent  view-point  for  the  subjective 
observer,  but  processes  in  the  macula  exert  the  chief  in- 


VISUAL   HALLUCINATIONS.  47 

fluence  in  the  production  of  many  visual  hallucinations. 
The  action  of  the  ocular  muscles  and  nerves  possesses  less 
importance. 

A  common  feature  of  all  the  shapes  arising  from  the 
retinal  light  proper  is  their  enlargement,  often  to  an 
enormous  extent.  This  is  probably  explained  by  the  near- 
ness of  the  object  seen,  especially  when  the  latter  is  sit- 
uated in  the  eye,  and  the  refracting  action  of  its  parts  is 
wanting.  These  hallucinations  appear  mainly  as  lights 
or  obscurations  in  the  shape  of  disks,  corresponding  to  the 
shape  of  the  yellow  patch.  When  these  discs  of  light  or 
darkness  burst  forth,  as  it  were,  from  the  macula,  they 
form  fruitful  material  for  morbid  manipulation  in  the 
concepts  of  the  brain.  The  healthy  individual  overlooks 
such  processes,  especially  as  they  do  not  develop  so  vio- 
lently, or  he  recognizes  the  mode  of  development'  and  is 
not  alarmed  thereby.  It  is  only  when  there  is  impairment 
and  restriction  of  consciousness  that  the  efficiency  of  ele- 
mentary sensory  deceptions  is  favored ;  hence  these  so-called 
peripheral  hallucinations  are  found  chiefly  in  such  con- 
ditions. In  this  relation  flames  and  lightning  are  terri- 
fying phenomena.  Fiery  points,  stars,  and  rays,  such  as 
appear  after  injury  to  the  eye,  also  on  coughing,  sneezing, 
or  bending  over,  as  a  rule,  are  observed  only  temporarily. 
But  if  they  are  prolonged,  as  in  fever,  they  form  the  ma- 
terial for  morbid  manipulation  in  the  concepts.  Local 
congestions  of  the  retinal  vessels,  and  the  toxic  action  of 
morbid  chemical  constituents  of  the  blood  upon  the  retinal 
termination  of  the  optic  nerves,  produce  peripheral  hallu- 
cinations in  fever,  and  especially  in  alcoholic  intoxication. 
In  the  delirium  of  alcoholism,  dark  or  shining  appearances 
develop  in  great  number  and  rapidity.  We  must  assume 
conditions  of  irritation  or  paralysis  in  the  macula  lutea, 
which  is  affected  by  variations  in  the  fulness  of  the  ves- 
sels. The  coincident  impairment  of  consciousness  does 
not  permit  any  explanation  of  these  sensory  impressions 
which  are  conveyed  to  the  brain,  and  they  are  interpreted 
as  crawling  insects,  rats,  mice,  pigs,  cows,  etc.    The  phe- 


48  HANDBOOK   OF   INSANITY. 

nomenon  sometimes  has  a  special  color  because,  after 
looking  for  a  long  time  at  colored  objects,  the  tired  retina 
sees  the  complementary  colors.  The  sky  often  furnishes 
the  opportunity  for  the  production  of  this  phenomenon. 

In  addition  to  the  blood-corpuscles  moving  in  the  ves- 
sels in  front  of  the  retina,  the  angular  pigment  epithelium 
and  the  roundish  granule  cells  also  furnish  material  for 
different  shapes.  If  the  sensory  deception  develops  in  one 
eye  alone,  the  possibility  of  distinguishing  it  from  a  unilat- 
eral hallucination,  which  has  developed  centrally,  is  to  be 
sought  in  the  fact  that  the  central  development  gives  rise 
to  much  more  complicated  phenomena.  We  then  find 
frequently  that  there  are  also  hallucinations  of  other 
senses,  and  these  are  combined  more  readily  with  other 
concepts.  Moreover,  peripheral  hallucinations  are  more 
pronounced  in  the  dark,  and  when  the  eyes  are  closed, 
than  in  a  bright  light. 

At  all  events,  the  entoptically  visible  masses  of  the  retina 
must  be  regarded  as  the  source  of  numerous  retinal  phan- 
tasms ;  as  the  products  of  nerve  substance  they  differ  from 
the  effects  of  the  external  world,  but  are  influenced  by  the 
latter  in  certain  respects.  The  movements  of  the  ocular 
muscles  and  the  retinal  pulsations  are  manifested  by  ap- 
parent movements  of  the  retinal  phantasms.  It  has  been 
ascertained  in  some  cases  that  visual  hallucinations  appear 
to  grow  larger  on  nearer  approach,  and  this  must  be  ex- 
plained by  the  influence  of  accommodation.  The  combina- 
tion of  light  and  dark  objects  in  the  entoptic  field  of  vision, 
with  the  movements  which  are  superadded  by  the  ocular 
muscles  or  retinal  pulsations,  suffice,  when  consciousness 
is  morbidly  restricted,  to  produce  the  notion  of  various 
running  animals  or  shapes.  As  this  variety  of  hallucina- 
tions depends  upon  the  presence  of  entoptic  masses,  we  can 
understand  the  great  variations  in  their  frequency  and 
extent,  in  otherwise  similar  morbid  conditions  of  the  brain. 
Under  physiological  conditions,  the  frequency  of  entoptic 
shapes  varies  greatly,  so  that  we  may  expect  this  form  of 
hallucinations  only  in  those  patients  who  have  already 


VISUAL   HALLUCINATIONS.  49 

experienced  these  peripheral  processes  during  periods  of 
health. 

The  condition  of  the  optic  nerve  in  its  path  to  the  brain 
furnishes  an  important  amplification  of  the  mode  of  devel- 
opment of  hallucinations.  Division  of  the  nerve  has  been 
known  to  abolish  previously  existing  hallucinations,  but, 
on  the  other  hand,  there  is  a  series  of  cases  in  which  hal- 
lucinations existed  despite  complete  atrophy  of  the  nerve. 
Hence  the  site  of  development  must  have  been  situated  cen- 
trally. Pathological  data  force  us  to  the  conclusion  that 
such  hallucinations  develop  in  the  cerebral  cortex,  probably 
only  in  the  occipital  and  parietal  lobes.  In  dementia  par- 
alytica in  which  the  anatomical  changes  are  confined 
commonly  to  the  frontal  lobes,  hallucinations  are  very 
rare ;  these  changes  have  also  been  found  in  the  posterior 
parts  of  the  brain  when  the  patients  exhibited  distinct  hal- 
lucinations during  life. 

Peculiar  interest  attaches  to  the  unilateral  appearance 
of  a  half  body,  for  example,  half  a  face  or  a  part  of  a 
card,  associated  with  a  loss  in  the  field  of  vision,  at- 
tributable to  an  interruption  of  conduction  in  the  corre- 
sponding optic  nerve.  This  could  only  be  understood  on 
the  assumption  that  the  material  for  the  hallucination  was 
collected  by  the  intact  optic  nerve  fibres,  and  hence  the 
memory  images  were  also  halved. 

Although  it  is  very  difficult,  in  individual  cases,  to 
prove  the  peripheral  or  central  origin  of  an  hallucination, 
this  differentiation  is  very  important.  It  must  be  remem- 
bered, however,  that  both  forms  may  occur  together.  The 
theory  that  hallucinations  only  develop  peripherally  as- 
sumes that  the  retina  possesses  a  sort  of  memory,  but  very 
little  proof  is  offered  in  favor  of  this  view.  The  manifold 
character  and  the  complicated  combinations  of  visual  hal- 
lucinations, derived  from  the  entire  experience  of  the  in- 
dividual, cannot  possibly  be  attributed  to  a  peripheral 
retinal  memory. 

That  memories  of  our  entire  range  of  experience  develop 
in  the  cortex,  is  one  of  the  most  assured  observations  of 
4 


50  HANDBOOK   OF   INSANITY. 

each  individual,  and  between  these  memories  and  halluci- 
nations there  is  a  difference  only  in  degree.  It  is  unjus- 
tifiable, however,  to  attribute  all  hallucinations  to  central 
causes.  The  vividness  of  some  hallucinations  appears  to 
be  explained  insufficiently  by  a  condition  of  irritation 
which  is  confined  to  the  cortex,  and  hence  it  was  inferred 
that  a  centrifugal  stimulus  passed  from  the  cortex  to  the 
terminal  distribution  of  the  optic  nerve.  It  was  claimed, 
in  support  of  this  mode  of  conduction,  that  the  phenomena 
sometimes  change  their  location  in  space  on  moving  the 
eye;  also  that  after-images  may  follow  hallucinations 
which  have  run  their  course,  for  example,  when  they  had 
developed  on  falling  asleep.  But  if  we  adhere  to  the  view 
that  some  hallucinations  develop  peripherally,  both  of  the 
cases  here  mentioned  can  be  easily  explained. 

Nor  does  the  vividness  of  other  central  phenomena  re- 
quire the  assumption  of  a  centrifugal  conduction  of  the 
irritation.  This  will  be  understood  on  studying  the  pri- 
mal property  of  nervous  substance  in  general,  and  which 
we  call  memory  in  the  broadest  sense  of  the  word.  All 
visible  objects  may  leave  more  or  less  permanent  impres- 
sions on  the  brain,  and  remain  as  memory-pictures  in  our 
memory.  They  may  regain  their  actual  distinctness, 
partly  by  directing  the  attention  upon  them  or  by  repeti- 
tion of  the  same  impressions  from  without.  This  process 
is  known  to  every  healthy  individual.  I  think  of  a  friend, 
and  at  once  his  image  stands  before  me.  This  faculty 
varies  greatly  in  different  individuals.  For  example, 
some  painters  can  paint  a  portrait  from  memory.  The 
only  material  difference  between  the  memory-picture  and 
the  actual  sensation  consists,  perhaps,  in  the  fact  that  the 
former  is  associated  with  the  idea  that  the  object  is  not 
really  present.  Between  such  memory-pictures  and  cen- 
tral hallucinations  there  is  only  a  difference  in  degree,  the 
process  is  always  the  recalling  of  the  memory-picture. 

It  is  a  striking  fact,  however,  that,  as  a  general  thing, 
only  a  few,  constantly  recurring  memories  form  the  con- 
tents of  hallucinations.     A  patient  constantly  sees  a  skull 


ILLUSIONS.  51 

upon  a  chair,  another  sees  a  black  object.  This  is  not  so 
astonishing,  however,  if  we  bear  in  mind  the  property  of 
nervous  tissues  to  recall  readily  past  experiences. 

The  special  causes  of  irritation  of  the  cortex  will  be  dis- 
cussed in  other  places.  Here  it  may  be  remarked  that 
the  absence  of  judgment  and  of  revision  by  other  regulated 
conceptions  gives  rise  to  fleeting  and  unconnected  images 
even  in  dreams.  When  the  attention  is  disturbed,  as  in 
insanity,  the  memory-pictures  of  the  irritated  cortex  may 
also  appear  in  the  waking  condition. 

Perhaps  there  is  an  alternate  action  between  the  per- 
ception-brain and  the  place  which  we  assume  as  that  of 
volitional  interpretation  of  the  internal  mental  processes, 
viz.,  the  apperception  organ  in  the  frontal  lobes,  in  which 
the  predominant  activity  of  one  part  produces  morbid  phe- 
nomena. It  is  most  disastrous  for  the  psychical  activity 
when,  with  stimulation  of  the  central  sensory  surfaces 
and  impaired  consciousness,  the  connection  of  ideas  and 
memory-pictures  takes  place  rapidly  and  independently  of 
the  will.  This  is  the  case  in  the  insane.  In  this  condition 
the  power  of  the  hallucinations  is  very  great,  and  it  is  true, 
in  a  certain  sense,  that  the  patient  not  alone  thinks  he  has 
visual  hallucinations,  but  that  he  really  sees  the  shapes. 
They  may  be  perceived  alongside  of  unchanged,  really  per- 
ceived external  objects.  The  overpowering  convincing 
effect  of  the  hallucinations  often  leads  the  patient  to  per- 
form the  most  senseless  acts. 

All  the  forms  of  hallucination  hitherto  mentioned  are 
thus  really  produced  by  processes  in  the  inner  life  of  man, 
or,  strictly  speaking,  in  his  central  nervous  system. 
These  are  grouped  together  under  the  term  visual  halluci- 
nations, and  are  distinguished  from  phantasms  whose  dis- 
tinguishing feature  it  is  that  they  are  produced  by  exter- 
nal objects ;  this  includes  all  objects  situated  in  front  of 
the  retina  and  also  the  corresponding  parts  of  the  eye 
itself.  To  these  the  term  illusion  is  applied.  A  normal 
consciousness  easily  recognizes  all  illusions  as  deceptions, 
and  corrects  them  by  the  aid  of  the  other  senses  and  quiet 


52  HANDBOOK   OF   INSANITY. 

reflection.  The  excited  or  irrational  patient  often  inter- 
prets external  objects  falsely.  Opacities  of  the  vitreous 
and  cornea  may  cause  illusions,  and  in  fact  all  processes 
which  give  rise  to  entoptic  shadows  on  the  retina.  There 
are  cases  of  unilateral  visual  illusion  which  disappeared 
after  iridectomy  or  extraction  of  the  lens,  or  even  after 
closing  the  lids. 

The  whole  of  visible  nature  may  be  the  field  of  these  illu- 
sions; they  develop  only  when  the  eye  sees  an  object  and 
hence  are  always  a  product  of  the  present.  Previous  im- 
pressions are  often  necessary  to  the  development  of  hallu- 
cinations. In  retinal  blindness  there  may  be  hallucina- 
tions but  no  visual  illusions.  In  the  darkness  of  night 
and  twilight,  the  excited  fancy  is  most  apt  to  adopt  false 
interpretations  of  ill-defined  visual  impressions. 

Finally,  in  broad  daylight  the  patient  sees  things  in 
shapes  which  are  different  from  the  reality,  and  then  there 
is  a  gradual  transition  between  illusions  based  on  a  false 
interpretation  of  objects,  and  purely  imaginary  concepts 
or  delusions.  Thus,  Don  Quixote  saw  giants'  arms  in- 
stead of  the  vanes  of  the  windmills.  Here  the  mode  of 
development  of  illusions  may  approach  very  closely  to  that 
of  hallucinations  proper,  because  impressions  acting  from 
without  are  often  no  longer  present.  Illusions  depend 
upon  error  of  recognition,  upon  a  false  interpretation  of 
external. objects.  Illusions  do  not  exclude  hallucinations. 
They  may  occur  at  the  same  time  in  one  individual,  and  it 
is  then  not  always  easy  to  distinguish  them.  Such  a  com- 
bination is  probably  of  common  occurrence,  and  the  refer- 
ence of  hallucinations  proper  to  the  external  world  is  so 
much  easier  when  they  are  favored  by  illusions  within 
and  in  front  of  the  eye. 

But  that  hallucinations,  like  ordinary  memory-pictures, 
are  per  se  referred  to  the  outside  world,  is  evident  from  the 
fact  that  such  memory-pictures  are  always  seen  in  front 
of  us,  even  when  the  eyes  are  closed ;  on  the  other  hand, 
it  is  very  difficult  to  transfer  the  memory-picture  behind 
one's  back. 


AUDITORY    HALLUCINATIONS.  53 

We  will  now  study  the  development  and  location  of 
auditory  hallucinations.  This  is  extremely  important,  be- 
cause it  touches  upon  the  domain  of  speech,  which  distin- 
guishes man  from  the  animals  and  forms  the  ways  and 
means  for  all  higher  mental  development.  Internal  hear- 
ing is  much  more  vivid  than  internal  vision.  It  is  the 
habit  of  man  to  think  in  word-images.  The  majority 
accompany  their  thoughts  with  the  special  form  of  lan- 
guage-images or  writing-images,  others  with  speech- 
images,  i.e.,  there  is  in  them  a  stimulation  of  the  speech 
muscles  by  the  brain.  Ideas  are  more  rarely  associ- 
ated with  writing  movements.  We  may,  therefore,  con- 
clude that  internal  hearing  is  associated  with  internal 
speaking.  Hence,  when  irritative  conditions  develop  in 
the  cortical  auditory  centres,  the  greatly  intensified  sound- 
images  and  word-images  are  not  alone  referred  to  the  outer 
world,  but  they  also  reach  the  highest  degree  of  distinct- 
ness, because  a  stimulus  also  passes  to  the  muscles  of 
speech.  Internal  speech  is  a  process  which  exhibits  the 
most  different  degrees  of  vividness  and  thus  indicates  the 
transition  between  healthy  and  morbid  mental  activity. 
As  a  matter  of  course,  it  does  not  accompany  every  cen- 
tral irritative  process,  but  when  it  does  the  auditory 
hallucinations  possess  overpowering  force.  They  are 
much  more  extensive  than  visual  hallucinations,  and  this 
must  be  attributed  to  the  frequent  combination  with 
speech-images.  This  association  of  word  and  idea  is  so 
firm  that  in  the  majority  of  people  every  thought  produces 
a  sensation  in  those  muscles  of  speech  which  would  be 
employed  in  actual  articulation.  These  slight  impres- 
sions of  movement  are  sufficiently  strong  to  act  recur- 
rently as  sensations  of  movement.  This  is  proven  by  the 
statement  of  many  who  suffer  from  auditory  hallucina- 
tions that  it  seems  to  them  as  if  their  thoughts  are  spoken 
or  repeated  internally,  as  if  communications  are  made  to 
them  through  the  agency  of  their  thoughts.  Thinking 
double  is  merely  another  term  for  the  same  process  of 
associated  movements  in  the  speech  muscles.     The  state- 


54  HANDBOOK   OP   INSANITY. 

ment  is  also  made  that  the  words  are  spoken  in  advance, 
before  they  have  been  uttered  by  the  patient,  as  if  they 
have  been  pressed  into  his  brain.  If  the  judgment  is  im- 
paired, these  words,  which  are  first  understood  internally, 
are  referred  to  the  outer  world,  and  then  the  notion 
follows  that  the  words  have  a  real  external  origin. 

This  does  not  exhaust  the  central  origin  of  auditory 
hallucinations.  The  memory-pictures  of  the  voice  of  cer- 
tain persons  are  easily  aroused ;  we  can  readily  recall,  in 
memory,  the  timbre  of  the  voices  of  members  of  our  family. 
Such  concepts  are  also  at  the  command  of  the  insane  and 
are  rapidly  associated  with  other  memory-pictures.  The 
patient  hears  the  voices  of  those  about  him  expressing  his 
own  thoughts.  In  explanation  of  this  process  the  patients 
call  these  hallucinations  internal  voices,  which  are  con- 
veyed by  the  telephone  or  telegraph,  recently  by  the  phono- 
graph. The  more  impaired  the  patient's  consciousness,  and 
the  more  ignorant  he  is,  the  more  readily  does  he  adopt  such 
an  explanation.  The  loudness  of  these  voices  varies  from 
the  gentle  internal  speech  of  the  healthy  man  to  the  most 
vivid  distinctness,  in  which  the  patient  really  hears  as  dis- 
tinctly as  if  the  words  were  spoken ;  indeed,  the  deception 
may  be  so  pronounced  that  the  words  drown  an  actual 
conversation.  There  are  also  cases  in  which  the  decep- 
tion does  not  seem  to  extend  beyond  the  patient's  body  and 
is  not  referred  to  the  outer  world ;  they  speak  of  thought- 
speech,  and  hear,  not  the  voices  of  deceased  individuals, 
but  their  thoughts  in  their  own  soul.  Or  the  voices  cause 
a  gentle  noise,  which  is  referred  to  some  part  of  their  own 
body ;  in  these  cases  it  is  probable  that  the  reference  of  the 
voices  to  any  part  of  the  body  is  due  to  a  morbid  sensation 
in  that  part. 

It  is  a  peculiar  expression  of  patients  with  auditory 
hallucinations  that  others  read  their  thoughts ;  the  pecu- 
liar character  of  their  own  speech  muscle  movements  seems 
to  be  described  in  this  way.  In  a  few  cases  the  patients 
themselves  have  noted  these  movements  of  the  organ  of 
speech.     We  are  not  justified  in  claiming  that  pure  inter- 


AUDITOKY   HALLUCINATIONS.  55 

nal  audition  precedes  internal  speech,  i.e.,  the  associated 
movements  of  the  speech-muscles,  but  the  association  of 
both  processes  varies  according  to  the  peculiarity  of  the 
affected  individual.  Whoever  is  in  the  habit,  as  a  healthy 
individual,  of  thinking  more  in  writing-concepts  than  in 
speech- concepts,  associates  the  auditory  hallucination  with 
a  writing-image,  and  this  probably  accounts  for  the  rare 
cases  in  which  the  hallucinated  word  is  seen  upon  the 
wall,  the  table,  etc. 

That  the  point  of  irritation  in  the  brain  possesses  ma- 
terial importance  is  shown  by  the  fact  that  unilateral  au- 
ditory hallucinations  have  been  observed  after  focal  lesions 
on  the  opposite  side  of  the  brain. 

We  must  now  determine  to  what  extent  true  hallucina- 
tions may  develop  in  the  course  of  the  auditory  nerve  and 
its  terminal  distribution.  Anatomically  it  must  be  noted 
that,  unlike  the  retina,  the  terminal  distribution  of  the 
auditory  nerve  (Corti's  organ)  is  not  developed  from  apart 
of  the  brain.  Hence,  there  is  no  reason  at  all  for  assum- 
ing a  peripheral  memory,  and  we  can  only  conjecture  that 
perhaps  diseases  of  Corti's  organ  may  be  direct  causes  of 
auditory  hallucinations. 

Deaf  people  may  experience  auditory  hallucinations,  in 
a  manner  analogous  to  the  visual  hallucinations  in  atrophy 
of  the  optic  nerve.  We  may  here  refer  likewise  to  the 
ability  of  great  musicians  to  compose  symphonies,  despite 
complete  deafness,  and  this  presupposes  almost  actual  dis- 
tinctness of  sound-concepts. 

There  are  numerous  causes  of  auditory  phantasms  out- 
side of  the  auditory  nerve,  and  these  must  be  included 
among  illusions.  Our  attention  is  first  attracted  by  so- 
called  entotic  noises ;  the  part  which  is  here  played  by  in- 
dependent irritative  conditions  of  the  termination  of  the 
auditory  nerve  cannot  be  estimated,  and  such  conditions 
must  be  examined  in  connection  with  those  causes  which 
appear  in  the  immediate  vicinity.  In  the  ear  itself  we 
find  inflammations  of  the  drum  membrane  and  cavity,  and 
all  those  conditions  which  increase  the  pressure  of  the  fluid 


56         •  HANDBOOK   OF   INSANITY. 

in  the  labyrinth.  Hence,  chronic  catarrh  is  the  most  fre- 
quent cause  of  noises  in  the  ear.  Congestion  and  inflam- 
mation of  the  semicircular  canals  act  in  the  same  way. 
Loud  and  persistent  noises  arise  from  pulsating  vessels, 
such  as  the  internal  carotid ;  or  roaring  noises  develop, 
especially  in  general  ansemia,  in  the  bulbus  of  the  internal 
jugular  vein  beneath  the  floor  of  the  middle  ear.  All 
these  sounds  may  become  the  material  of  illusions  when 
consciousness  is  disturbed,  but  the  healthy  individual 
usually  secures  the  proper  interpretation.  The  latter,  how- 
ever, often  refers  the  whistling,  etc.,  to  the  external 
world  until  experience  teaches  him  that  the  noise  is 
located  in  his  own  head.  Other  bodily  sounds,  such  as 
the  movements  of  air  and  gases  in  the  bowels,  rales  in  the 
lungs,  and  heart  sounds  may  also  constitute  the  material 
for  illusions. 

All  real  sounds  of  the  outer  world  may  also  be  falsely 
interpreted  into  illusions,  and  here  the  close  relationship 
is  shown  between  auditory  illusions  and  delusions. 

As  a  matter  of  course,  hallucinations  and  illusions  of 
hearing  may  exist  together.  Many  of  these  patients  stop 
their  ears.  This  is  perhaps  explained  by  the  assumption 
that  illusions  due  to  the  ill-defined  noises  of  every-day  life 
(rattling  of  wagons,  etc.)  are  thus  prevented,  but  the  at- 
tempt will  be  partly  useless  and  only  explicable  in  view  of 
the  undoubted  attempt  to  prevent  hallucinations  which  are 
referred  to  the  outer  world. 

Hallucinations  and  illusions  of  smell  cannot  be  distin- 
guished separately  except  in  those  very  different  cases  in 
which  they  are  produced  in  the  central  olfactory  cortex  or 
in  which  they  are  due  to  the  interpretation  of  causes  situ- 
ated outside  of  the  body.  The  boundary  between  the  ter- 
minal distribution  of  the  olfactory  nerves  and  the  adjacent 
mucous  membrane  does  not  allow  us  to  decide  practically 
between  peripherally  developed  hallucinations  and  illusions 
based  on  processes  within  the  body.  Although  we  may 
regard  peripheral  olfactory  hallucinations  as  possible,  they 
are  the    same,    for    our  purposes,    as    illusions.     Nasal 


OLFACTORY   HALLUCINATIONS.  57 

catarrhs,  congestion  and  proliferations  of  the  mucous 
membrane,  and  all  other  pathological  changes  in  the  nose 
are  among  the  causes  of  illusions.  Smells  which  actually 
develop  in  any  part  of  the  body,  such  as  the  smell  of  de- 
composing epithelium  of  the  tongue,  may  give  rise  to  the 
notion  of  decomposition  or  poisoning.  The  possibility  of 
the  misinterpretation  of  all  smells  in  the  external  world 
into  illusions  is  also  easily  understood. 

Disagreeable  olfactory  hallucinations  have  also  been 
observed  in  progressive  destruction  of  the  olfactory  nerves 
by  tumors,  so  long  as  an  irritative  condition  of  the  nerve 
persisted.  Very  few  cases  of  true  hallucinations  have  been 
observed  after  entire  destruction  of  the  nerves.  A  notice- 
able phenomenon  is  the  loss  of  smell,  lasting  hours  or  days, 
in  persons  suffering  from  increased  cerebral  pressure. 
This  must  be  attributed  to  variations  in  pressure,  and  per- 
haps this  cause  partly  explains  the  periodical  occurrence 
of  olfactory  hallucinations.  This  may  also  be  true  of  the 
other  nerves  of  special  sense. 

Concerning  the  olfactory  hallucinations  which  develop 
in  the  central  olfactory  area,  not  much  can  be  said,  be- 
cause its  location  in  the  cortex  is  not  positively  known. 
It  is  a  very  striking  clinical  fact  that  olfactory  hallucina- 
tions are  often  associated  with  morbid  sexual  phenomena. 

The  development  and  situation  of  gustatory  hallucina- 
tions are  very  similar  to  those  of  smell.  They  are  also 
very  rare,  but  not  devoid  of  importance,  as  they  sometimes 
lead  to  refusal  to  take  food.  The  difference  between  hallu- 
cinations and  illusions  becomes  indistinct  at  the  boundary 
between  central  and  peripheral  parts.  Very  often  the 
possibility  of  direct  effects  of  processes  in  the  mucous 
membranes  cannot  be  excluded  in  the  "  contact "  senses  of 
smell  and  taste.  For  example,  the  chemical  action  of  de- 
compositions in  the  buccal  cavity  undoubtedly  plays  a  fre- 
quent part.  The  possibility  of  a  purely  central  develop- 
ment is  shown  by  the  fact  that  gustatory  hallucinations 
are  often  combined  with  those  of  smell,  hearing,  and  sight. 

Great  practical  importance  attaches  to  hallucinations  of 


58  HANDBOOK   OP   INSANITY. 

feeling.  The  main  difficulty  in  examination  is  found  at 
the  boundary  line  between  hallucinations  and  illusions. 
The  wide  distribution  of  the  terminal  nerves  in  the  integu- 
ment, mucous  membranes,  and  internal  organs  leads  to  a 
further  difficulty.  In  almost  all  cases  only  small  parts  of 
the  entire  sense  of  feeling  are  to  be  examined.  We  must 
determine  whether  these  belong  to  definite  peripheral  nerve 
tracts  or  to  tracts  whose  nerves  unite  only  in  the  centres. 
In  the  latter  event  the  deception  of  feeling  probably  is  pro- 
duced in  the  brain,  i.e.,  it  is  an  hallucination,  in  the  for- 
mer event  it  may  also  be  an  illusion.  In  the  skin  the 
proof  of  such  connection  is  not  often  possible,  it  is  easier 
in  the  mucous  membranes  and  internal  organs.  The 
demonstration  that  hallucinations  develop  peripherally  in 
the  skin  is  not  practicable,  because  we  are  not  accustomed 
to  refer  cutaneous  sensations  to  any  other  parts.  On  ac- 
count of  this  peculiarity  cutaneous  sensibility,  as  a  contact 
sense,  is  closely  related  to  smell  and  taste.  In  the  main  it 
is  mechanical  impressions,  and  also  differences  in  degrees 
of  heat,  which  give  rise  to  illusions  of  the  sense  of  feeling. 
A  proof  of  the  view  that  deceptions  of  feeling  are  com- 
monly illusions  is  found  in  the  fact  that,  as  a  rule,  the 
patients  merely  compare  their  sensations  with  similar  pro- 
cesses. But  after  the  illusion  has  lasted  a  long  time,  its 
original  cause  disappears  in  the  patient's  mind  and  may 
pass  into  his  memory,  whence  it  may  appear  later  as  an 
independent  hallucination.  This  is  also  true  of  the  other 
Senses.  The  well-known  notion  of  the  presence  of  an 
amputated  limb  affords  an  illustration  of  an  hallucination 
which  has  become  central,  after  the  original  irritative 
phenomena  in  the  cicatrix  of  the  nerves  have  disappeared. 
This  process  is  a  complicated  one,  however,  on  account  of 
the  implication  of  the  muscular  sense.  Indeed,  this  can 
often  not  be  separated  from  cutaneous  sensibility  in  con- 
sidering deceptions  of  feeling.  When,  for  example,  un- 
usual positions  of  the  limbs  give  rise  to  illusions  in  dis- 
eases attended  with  cutaneous  insensibility,  this  is  due  to 
the  peripheral  terminations  of  the  nerves  in  the  muscles.. 


HALLUCINATIONS   ORIGINATING   IN  VISCERA.  59 

The  central  origin  of  muscular  sense  may  also  give  rise  to 
hallucinations,  as  is  shown  by  the  remarkable  feeling  as  if 
the  patient  were  flying. 

The  combination  of  correctly  interpreted  perceptions  with 
misinterpretation  of  other  impressions  is  found  most  fre- 
quently in  ideas  concerning  the  condition  of  the  viscera. 
This  is  particularly  true  of  the  hypochondriac.  Deceptions 
concerning  the  condition  of  the  genitalia  are  very  impor- 
tant in  this  regard ;  also  the  disturbance  known  as  imper- 
fect feeling  of  satiety  which  is  often  due  to  gastric  affec- 
tions. All  other  viscera  whether  healthy  or  diseased  may 
also  cause  changes  of  common  sensibility  and  thus  lead  to 
deceptions.  This  common  sensibility  undoubtedly  has  a 
central  origin,  as  is  shown  particularly  by  the  occurrence 
of  numerous  associated  sensations  which  depend  on  irrita- 
tive conditions  of  the  most  varied  nerves.  Pain  is  the  most 
important  disturbance  of  common  sensibility,  and  is  very 
significant  in  the  development  of  hallucinations.  But  if 
diseases  of  the  nerve-fibres  themselves  are  converted  into 
delusions,  we  see  that  falsely  interpreted  sensations  are  not 
always  true  sense-deceptions,  and  that  the  difference  be- 
tween these  two  forms  of  disturbance  of  the  perceptive  pro- 
cess must  be  maintained. 

Hallucinations  in  general  are  connected  with  the 
contents  of  consciousness  at  the  time,  and  this  is  shown 
most  clearly  when  the  thoughts  are  expressed  aloud. 
As  auditory  hallucinations  occur  chiefly  in  chronic  dis- 
orders they  form  the  most  frequent  variety;  and  their 
connection  with  thoughts  entertained  at  the  time  is  very 
common  and  is  expressed  in  speech.  The  patient  calls 
these  processes  "voices,"  although  numerous  other  noises 
are  also  heard.  The  auditory  hallucinations  are  usually 
of  a  disagreeable,  distressing  character.  Reproaches,  in- 
sults, and  ironical  remarks,  generally  in  short  sentences, 
excite  the  patient  and  lead  him  to  commit  violence 
against  his  supposed  revilers  and  persecutors.  Their 
threats  impel  him  to  flee;  their  commands  lead  to  sense- 
less and  unnatural  acts,  especially  when  they  are  ascribed 


60  HANDBOOK   OF    INSANITY. 

to  higher  powers.  The  pitch  and  timbre  of  the  voices  are 
often  distinguished,  and  are  then  ascribed  to  different  per- 
sons. They  speak  in  a  whispering  or  hissing  tone,  from 
a  distance,  from  above  or  from  the  floor ;  at  other  times, 
they  are  so  loud  that  all  other  sounds  are  drowned.  More 
rarely  the  patients  hear  loud  noises,  music,  or  singing ;  in 
the  rarest  case's  do  they  have  an  agreeable  character.  The 
patients  hear  hammering,  ringing  of  bells,  or  the  driving 
of  nails  into  a  coffin.  They  are  usually  associated  with 
visual  hallucinations,  in  the  shape  of  supernatural  beings.' 
God  or  Christ  appears  to  the  patient,  promises  him  future 
greatness,  directs  him  as  to  the  manner  in  which  to  obtain 
his  rights.  As  the  auditory  hallucinations  return  to  the 
circle  of  ideas  from  which  they  have  usually  developed, 
they  form  a  constant  stimulus  for  the  same  delusions. 

In  a  fewer  number  of  cases  the  voices  are  entirely  for- 
eign to  the  patient's  ideas  and  thus  excite  still  greater 
terror. 

The  contents  of  visual  hallucinations  are  not  always  so 
unpleasant.  As  they  occur  most  frequently  in  acute  affec- 
tions, they  are  cheerful  or  depressed,  according  to  the 
character  of  the  psychical  disorder.  The  usually  peri- 
pheral hallucinations  of  the  alcoholic  consist  of  mice,  rats, 
birds,  insects,  whose  rapid  movements  often  provoke 
the  patient's  mirth,  but  sometimes  terrify  him.  Other 
peripherally  developing  light-phenomena  are  masses  of 
fire  or  light;  the  patient  imagines  himself  in  heaven, 
and  sees  the  glory  of  God,  or  believes  he  is  surrounded 
by  the  flames  of  hell.  The  more  impaired  consciousness 
is,  the  more  terrible  do  the  contents  of  such  visual  hallucina 
tions  become,  and  these  conditions  of  terror  are  sometimes 
of  frightful  violence — for  example,  in  epileptics. 

However,  not  all  statements  of  the  patient  concerning 
visual  hallucinations  may  be  accepted  unreservedly. 
They  are  often  merely  dreams  which  are  regarded  as  real, 
or  the  patient  has  a  tendency,  when  leading  questions  in 
this  direction  are  asked,  to  boast  of  fleeting  ideas  as  dis- 
tinct sense-perceptions. 


COMBINED    HALLUCINATIONS.  61 

Olfactory  hallucinations  are  usually  disagreeable  in 
character.  The  smell  of  a  cadaver  or  of  sulphur  is  often 
mentioned ;  the  delusion  of  poisoning  and  refusal  to  take 
food  often  accompany  such  hallucinations.  The  majority 
of  gustatory  hallucinations  are  also  disagreeable  and  are 
generally  attributed  to  mixtures  with  food.  In  a  few  cases 
the  hallucinations  are  pleasant. 

Hallucinations  of  feeling  are  very  numerous  and  vary- 
ing. They  are  more  frequently  pleasant  than  hallucina- 
tions of  other  senses,  yet  the  disagreeable  ones  predomi- 
nate. This  is  especially  true  at  the  onset,  when  they  are 
generally  foreign  to  the  contents  of  the  patient's  ideas. 
With  increasing  mental  weakness  their  disagreeable  na- 
ture disappears.  We  must  not  regard  as  real  all  the 
strange  judgments  which  patients  affirm  concerning  their 
true,  but  falsely  interpreted  sensations.  The  patient  em- 
ploys peculiar  expressions  to  express  his  sensations. 
Pinching,  pricking,  burning,  tearing,  which  indicate  a 
peripheral  origin,  are  frequently  employed.  These  are 
often  combined  with  statements  that  the  patients  are  being 
magnetized — evidently  an  attempt  to  explain  the  sensa- 
tions. Their  contents  also  depend  greatly  on  the  feelings 
which  arise  from  the  condition  of  the  viscera. 

Hallucinations  of  several  senses  are  very  commonly 
associated  with  one  another.  This  is  particularly  true  of 
the  contact  senses,  especially  smell  and  taste.  Auditory 
hallucinations  are  often  observed  alone;  visual  hallucina- 
tions are  hardly  ever  independent  of  hallucinations  of 
hearing  or  feeling. 

The  strength  of  hallucinations  varies  during  the  disease, 
being  less  at  the  beginning  and  end;  they  rarely  cease 
suddenly.  When  recovery  begins,  the  visual  hallucina- 
tions usually  become  less  vivid,  the  outlines  become 
vague,  auditory  hallucinations  become  remote  and  indis- 
tinct. At  this  time  the  patient's  attention  may  be  drawn 
to  the  morbid  character  of  his  condition  in  order  to  has- 
ten recovery.  But  even  then  caution  is  necessary,  be- 
cause attention  should  not  again  be  called  to  the  disap- 


62  HANDBOOK   OF    INSANITY. 

pearing  conditions.  It  is  entirely  wrong,  however,  to 
attempt,  at  the  height  of  the  disease,  to  reason  the  patient 
out  of  his  hallucinations.  This  is  usually  harmful  because 
the  patient's  mistrust  is  excited  or  increased. 

Hallucinations  occur  not  alone  in  mental  disturbances, 
so  that  they  must  be  associated  with  a  change  in  the 
entire  personality  before  they  justify  the  diagnosis  of 
insanity. 

2.  The  Disturbances  of  Consciousness  during  Sleep 
and  Dreams.  Associated  States  of  Impaired  Con- 
sciousness and  Hypnotic  Conditions. 

Sleep  is  related  so  closely  to  mental  activities  and  dis- 
turbances that  it  becomes  necessary  to  investigate  its 
cause.  As  a  rule,  two  causes  co-operate  in  its  production, 
viz.,  the  exhaustion  of  the  central  nervous  system  and  the 
diminution  of  attention.  Sleep  is  associated  with  the  ac- 
tivity of  the  apperception  organ ;  inhibitory  effects  upon 
the  movements  of  the  heart,  respiration,  etc.,  are  pro- 
duced ;  during  their  influence  the  psychophysical  side  of 
mental  life  rests  and  recuperates.  An  increase  or  diminu- 
tion of  the  regular  periodical  function  of  the  brain,  which 
appears  in  the  shape  of  sleep,  may  be  one  of  the  most  strik- 
ing signs  of  mental  disturbance. 

The  most  important  is  insomnia,  because  it  is  not  alone 
a  sign  but  a  cause  of  the  development  of  the  psychical  dis- 
order. Restless  sleep  may  also  occur  constantly  in  a 
healthy  individual,  but  when  it  is  a  new  sign  it  acquires 
greater  importance. 

Somnambulism  is  a  more  important  symptom.  As  a 
rule  during  sleep,  more  rarely  in  the  daytime  after  hys- 
terical or  epileptic  seizures,  the  patients  walk  about,  per- 
form various  acts,  even  commit  crimes,  and  then  lie  down, 
without  having,  on  awaking,  more  than  a  confused  mem- 
ory of  such  events.  During  the  attack  the  disturbance 
of  consciousness  is  usually  not  very  profound,  because  the 
individual  is  often  awakened  by  noises  or  sudden  contact. 
The  sureness  of  movement  amid  dangerous  surroundings, 


SOMNOLENCE.  63 

for  example,  in  walking  upon  a  roof,  can  only  be  explained 
by  the  imperfect  conception  of  the  situation,  where  danger 
is  not  recognized,  so  that  dizziness  and  fear  are  wanting. 

A  more  profound  disturbance  of  consciousness  is  ex- 
hibited in  the  various  forms  of  somnolence.  Conscious- 
ness is  impaired  or  entirely  wanting  for  long  periods; 
these  are  only  interrupted  for  short  intervals  during  which 
the  ingestion  of  food  and  the  wants  of  nature  are  attended 
to.  These  conditions  are  distinguished  from  normal  sleep 
by  their  long  duration  and  by  their  causation ;  this  may 
consist  of  an  organic  disease  of  the  brain  or  a  purely  ner- 
vous cause,  with  or  without  previous  exhaustion. 

The  so-called  dream  conditions,  which  appear  in  attacks 
of  longer  or  shorter  duration,  are  a  peculiar  form  of  im- 
pairment of  consciousness.  Special  importance  attaches 
to  those  which  develop  during  or  after  spasmodic  seizures, 
and  in  which  violent  acts  are  occasionally  performed.  Psy- 
chologically we  have  to  deal  with  a  disorder  in  the  interpre- 
tation of  all  impressions  by  the  attention,  and  everything 
points  to  a  disturbance  of  the  apperception  organ,  explica- 
ble by  variation  of  the  amount  of  blood  in  the  cerebral  cor- 
tex. At  the  end  of  this  series  of  different  degrees  of  im- 
paired consciousness  stands  unconsciousness  in  which 
physiological  stimuli  are  no  longer  converted  into  mental 
processes.  The  unconsciousness  may  be  temporary,  as  in 
drunkenness,  severe  convulsions,  febrile  conditions,  inflam- 
mations of  the  brain ;  or  permanent,  in  the  course  of  many 
chronic  forms  of  insanity,  especially  in  imbecility. 

The  unconsciousness  of  sleep  may  suffer  an  interruption 
which  leads  to  a  changed  condition  in  the  shape  of  dreams. 
Products  of  decomposition  arising  from  the  processes  of 
disassimilation  act  during  sleep  as  irritants  and  overcome 
the  existing  inhibitions  so  that  individual  concepts  appear 
and  may  be  united  with  feeble  sensory  impressions.  The 
latter  are  illusions,  but  may  be  associated  with  true  hallu- 
cinations arising  from  memory-concepts,  and  may  enter 
the  impaired  consciousness.  The  most  abundant  material 
is   offered  by  the   movements  and   processes  within  the 


64  HANDBOOK   OF   INSANITY. 

body,  the  muscse  volitantes,  and  auditory  impressions  due 
to  tinnitus. 

It  is  an  important  fact  that  dream-like  conditions  may 
be  produced  by  certain  poisons  and  drugs.  Atropine 
arouses  memory-pictures  of  ugly  and  terrifying  things, 
cannabis  indica  of  beautiful  things,  ether  produces  the  feel- 
ing of  flying  in  infinity.  Hence,  different  mental  activi- 
ties are  excited  singly,  or,  as  in  chloroform  narcosis,  a 
definite  order  in  the  implication  of  certain  parts  of  the 
brain  can  be  recognized.  Dreams  are  thus  characterized 
as  morbid  processes,  but,  like  central  hallucinations,  they 
grow  insensibly  out  of  normal,  undisturbed  sleep. 
Whether  this  partial  activity  of  the  brain  in  artificial  and 
natural  dreams  is  accompanied  and  caused  by  circulatory 
conditions  cannot  be  proven,  but  may  be  assumed  from  its 
similarity  to  the  condition  of  sleep. 

Allied  to  sleep  is  the  disturbance  of  consciousness 
known  as  hypnosis.  The  latter  is  distinguished  from  sleep 
by  the  fact  that  only  some  of  the  cerebral  functions  are 
inhibited.  Unlike  somnambulism,  hypnosis  is  an  artifi- 
cially produced  condition.  After  the  hypnotized  indi- 
vidual has  passed  into  a  condition  of  half-sleep,  in  which 
catalepsy  finally  develops,  the  peculiar  stage  of  hypnosis 
proper  develops.  Voluntary  movements  are  again  possi- 
ble, and  sensory  impressions  may  be  received,  but  con- 
sciousness is  restricted  in  a  peculiar  manner,  so  that  it  is 
only  susceptible  to  certain  external  impressions.  The  indi- 
vidual may  be  led  by  suggestion  because  the  fully  inde- 
pendent faculty  of  active  attention  is  wanting.  Hence, 
this  disorder  must  be  sought  in  the  apperception-organ. 
Experience  shows  that  the  frequent  production  of  hypnosis 
may  lead  to  mental  disturbance,  especially  as  persons 
suffering  from  an  hereditary  taint  are  best  adapted  to  hyp- 
nosis. Although  favorable  results  from  the  employment 
of  hypnosis  in  the  treatment  of  psychical  affections  have 
been  reported,  the  condition  is  still  so  obscure  that  we 
cannot  yet  recommend  it  to  the  practical  physician.  Apart 
from  so-called  hypnosis  major,   which  is  due   in   great. 


CATALEPSY.  65 

measure  to  an  hysterical  basis,  ordinary  artificial  hypnosis 
may  be  regarded  as  a  partial  sleep.  The  assumption  also 
appears  to  be  justified  that  the  differences  between  sleep 
and  hypnosis  are  due  to  the  varying  rapidity  with  which 
the  different  senses  are  put  to  sleep,  hearing  and  muscular 
sense  being  the  last  to  become  exhausted.  The  decisive 
influence  is  exercised  by  attention,  and  in  this  connection 
we  may  assume  longer  or  shorter  periods  of  contraction  of 
individual  vascular  tracts  in  the  brain  as  the  intermediate 
accompanying  phenomena. 

Much  more  importance  attaches  to  catalepsy,  which  is 
either  a  part  of  other  diseases,  or  appears  independently. 
It  is  a  symptom-complex,  composed  of  impaired  conscious- 
ness, with  anaesthesia,  muscular  rigidity,  and  more  or 
less  flexibility  of  the  limbs.  Retention  of  urine  and  depri- 
vation of  food  are  subordinate  symptoms,  which  are  ex- 
plained by  the  motor  and  psychical  condition.  The  term 
catalepsy  is  also  employed  when  one  or  the  other  of  these 
symptoms  is  absent.  The  basis  is  always  a  mental  dis- 
turbance of  some  kind,  hysteria,  melancholia,  progressive 
paresis  with  weakness,  or  a  more  independent  disorder  of 
consciousness.  Upon  this  basis  develops  the  peculiar  mus- 
cular rigidity,  associated  with  so-called  waxen  flexibility. 
This  combination  is  difficult  to  understand  physiologically ; 
the  tetanic  rigidity  first  develops,  later  the  flexibility. 
The  explanation  is  not  proven  but  plausible  that  the  rigidity 
is  due  to  unequal  innervation  of  antagonistic  muscles, 
while,  in  waxen  flexibility,  they  are  innervated,  at  any  mo- 
ment, with  complete  uniformity.  The  condition  is  gener- 
ally involuntary,  but  sometimes  semi- voluntary  as  the  re- 
sult of  delusion  or  as  a  sort  of  play,  and  is  then  confined 
to  a  few  groups  of  muscles.  Hysterical  individuals  and 
some  paretics  have  a  tendency  in  this  direction.  As  a 
matter  of  course,  a  certain  degree  of  clearness  of  con- 
sciousness is  then  necessary.  The  more  consciousness  is 
impaired,  the  more  general  is  the  extent  of  the  motor 
symptoms.  The  location  of  catalepsy  must  be  referred  to 
the  frontal  lobes,  the  disturbance  of  consciousness  point- 
5 


66  HANDBOOK   OF   INSANITY. 

ing  to  the  apperception-organ,  the  motor  symptoms  to  the 
adjacent  central  convolutions. 

Stupor  and  ecstasy  may  resemble  catalepsy  in  their  out- 
ward manifestations,  but  have  a  different  origin.  These 
disturbances  of  consciousness  are  associated  with  definite, 
partly  voluntary  and  conscious  notions.  According  as 
these  concepts  are  sad  or  cheerful,  stupor  or  ecstasy  will 
be  produced.  Self -consciousness  is  not  entirely  abolished, 
but  the  ability  to  concentrate  the  attention  actively  is 
merely  impaired,  slowed,  or  accelerated.  Hence,  stupor 
and  ecstasy  may  be  influenced  by  delusions  which  are 
generally  absent  in  catalepsy.  But  as  an  organic  basis  is 
not  wanting  in  stupor,  it  is  associated  with  other  symp- 
toms, such  as  slow,  superficial  respiration,  circulatory  dis- 
turbances, slowness  of  digestion,  etc.  As  the  final  effect 
of  a  melancholic  condition,  stupor  very  often  passes  grad- 
ually into  dementia.  The  inability  to  distinguish  these 
conditions  accurately  is  evident  from  the  fact  that  the 
term  stupor  is  also  applied  to  conditions  of  exhaustion 
after  epileptic  convulsions,  maniacal  excitement,  and  fe- 
brile diseases.  Ecstasy  is  distinguished  from  catalepsy 
only  by  its  development  from  delusions,  and  its  combination 
with  hallucinations. 

3.  Disorders  of  Self -Consciousness. 

The  above-mentioned  signs  of  mental  disturbances,  es- 
pecially of  consciousness,  necessitated  a  distinction  between 
consciousness  in  general  and  self-consciousness.  We  have 
already  applied  the  term  consciousness  to  the  occurrence  of 
impressions  of  internal  and  external  experience,  and  their 
conversion  into  mental  processes.  In  the  to-and-fro 
movement  of  concepts  in  this  consciousness,  one  group  of 
coherent  individual  concepts  is  distinguished  apart  from 
the  others ;  it  is  the  group  whose  source  resides  in  our- 
selves. The  sensory  concepts  received  from  our  own 
body  and  the  movement-concepts  of  our  limbs  are  co- 
herent and  permanently  present.  At  any  time  they  are 
readily  associated  with  other  concepts,  according  to  habit 


CHANGE   IN   THE   EGO.  67 

or  voluntary  effort.  This  consciousness  of  our  own  per- 
sonality is  self-consciousness.  In  mental  disorders  a  change 
of  self -consciousness  may  be  one  of  the  most  prominent 
signs  of  disease.  The  most  important  form  of  the  disor- 
ders of  self-consciousness  is  the  consciousness  of  disease. 
Long  before  the  beginning  of  the  disease  proper,  there  is 
often  a  terrifying  feeling  of  impending  loss  of  reason,  es- 
pecially in  individuals  with  an  hereditary  taint.  This 
feeling  is  sometimes  so  vivid  that  the  patient  seeks  admis- 
sion into  an  insane  asylum.  Even  at  the  height  of  the 
disease  some  patients  feel  that  there  is  a  disturbance  in 
the  course  of  their  moods  which  is  not  dependent  on  ex- 
ternal influences.  As  a  rule,  morbid  general  sensations 
constitute  the  direct  basis  of  this  diseased  self-conscious- 
ness. But  while  the  patient  is  struggling  against  the  con- 
stantly recurring  morbid  impressions  and  feelings,  the 
well-defined  concept  of  his  own  ego  is  becoming  changed. 
Here  it  loses,  there  it  gains  elements  by  detachment  or 
combination  with  other  groups  of  concepts,  and  with  the 
feeling  of  resistance  the  normal  self -consciousness  disap- 
pears or  changes  more  and  more.  The  association  with 
the  past  is  lost,  and  the  present  personality  appears  foreign 
to  the  former ;  if  fragments  of  the  former  have  been  re- 
tained, delusions  of  double  personality  may  develop.  At 
other  times  self -consciousness  disappears  so  completely  that 
the  patient  regards  himself  only  as  an  object,  or  even  this 
becomes  so  remote  from  the  circle  of  inner  self -observation 
that  a  nihilistic  delusion  develops,  the  notion  that  nothing 
exists  or  that  the  person  of  the  patient  no  longer  exists. 
This  absence  of  self-consciousness  has  been  often  found 
associated  with  atrophy  of  the  cortex,  especially  in  demen- 
tia paralytica — another  proof  that  the  frontal  lobes  are  in- 
timately related  with  these  disorders.  But  apart  from 
these  special  forms  of  the  feeling  of  being  sick,  it  is  one 
of  the  most  striking  and  widespread  symptoms  in  almost 
every  psychical  affection  that  this  feeling  is  lost  after 
the  affection  has  lasted  a  long  time.  Patients  in  an  asy- 
lum often  exhibit  a  clear  comprehension  of  the  speech  and 


68  HANDBOOK    OF   INSANITY. 

acts  of   their  fellow-patients,  but  have   false   judgments 
concerning  themselves. 

The  convalescent  patient  recovers  his  former  self-con- 
sciousness and  gains  a  clear  insight  into  his  disease.  This 
is  one  of  the  most  important  signs  of  beginning  or  com- 
pleted recovery  after  disturbances  of  self -consciousness  and 
mental  diseases  in  general. 

B.       DISTURBANCES     IN     THE    ASSOCIATION     AND     COURSE 

OF   IDEAS. 

The  disturbances  of  consciousness  which  we  have  con- 
sidered in  the  previous  section  are  observed,  in  not  a  few 
cases,  in  those  who  are  mentally  healthy.  The  disorders 
in  the  association  and  course  of  ideas,  which  we  will 
now  discuss,  may  also  occur  occasionally  in  the  sane,  but 
in  general  they  are  evidence  of  an  already  existing  or 
developing  mental  disorder. 

1.  Apperception  and  Association. 

As  the  boundaries  of  inner  experience  are  also  the  limits 
of  consciousness,  the  elements  of  the  disorders  now  under 
consideration  belong  within  these  limits,  inasmuch  as 
they  also  occur  within  that  broad  field  of  cerebral  life  from 
which  individual  concepts  may  reach  apperception.  We 
must  distinguish,  however,  whether  the  material  of  the 
concepts  is  called  forth  actively  by  attention  or  is  passively 
noticed.  In  the  flow  of  cerebral  life  concepts  appear  in 
great  numbers ;  if  a  sort  of  struggle  ensues  between  them 
to  reach  apperception,  we  feel  this  internal  activity  as  an 
action  to  which  we  apply  the  term  active  attention.  But  if 
one  of  the  concepts  in  question  is  favored  by  its  characteris- 
tics to  such  an  extent  that  the  apperception  of  another  con- 
cept cannot  come  into  question,  it  is  received  merely  by 
passive  attention.  With  the  ideas  which  are  aroused  by 
external  sensory  impressions  are  constantly  combined  the 
memory-pictures  of  former  ideas ;  the  association  of  the 
ideas   furnishes  the  material  from  which    the  attention 


ASSOCIATION   OF  IDEAS.  69 

collects  individual  elements.  When  the  selection  is  made 
from  a  number  of  such  concepts,  the  attention  is  active  and 
only  brings  up  one  after  another  for  interpretation ;  the 
attention  is  passive  when  an  undoubted  association  of  in- 
dividual concepts  has  taken  place.  The  lunatic  is  very 
often  in  such  a  position  that  he  is  only  passively  and  not 
actively  attentive  to  the  internal  processes  of  his  experi- 
ence, and  constantly  grows  more  and  more  impotent 
against  the  successively  appearing  ideas  and  bheir  com- 
binations. Not  alone  the  present  concepts  come  into 
play,  but  the  entire  prior  development  of  consciousness  is 
superadded.  There  is,  however,  an  imperfect  interpreta- 
tion of  the  concepts  which  have  developed  in  the  past  and 
the  present,  and  their  irregular  combination  leads  to  in- 
coherency.  When  active  attention  has  not  yet  disap- 
peared entirely,  the  disorder  appears  as  absent-minded- 
ness. When  active  attention  ceases  entirely  we  find  con- 
ditions in  which  the  combination  of  ideas  may  even  be 
made  to  depend  upon  the  will  of  others,  as  in  suggestion. 
This  is  done  experimentally  in  hypnotism,  and  the  so-called 
epidemic  spread  of  mental  disorders  is  also  explained  in  a 
similar  way.  The  predominance  of  irregular  combina- 
tions of  concepts  over  the  regular  arrangement  into  clear 
notions  is  the  first  and  most  important  sign  of  mental 
weakness.  In  congenital  and  acquired  feeble-mindedness 
there  is  no  regular  and  close  combination  of  new  and  old 
concepts.  But  in  all  conditions,  which  vary  from  mental 
health  to  complete  imbecility,  the  disturbance  appears  in 
the  greater  or  less  difficulty  of  active  selection  among  the 
concepts  and  their  combinations.  Purely  external  influ- 
ences make  themselves  felt,  as,  for  example,  the  association 
of  ideas  with  words  of  similar  sound,  which  are  either 
spoken  by  the  patient  himself  or  by  others.  Such  persons 
are  apt  to  speak  in  verses  which  have  no  connection  and 
merely  show  a  relation  of  sounds,  especially  of  the  terminal 
words.  Other  patients  grasp  only  a  single  word  in  a  con- 
versation and  associate  with  this  the  series  of  ideas  which 
are  then  appearing  in  their  consciousness. 


70  HANDBOOK   OF   INSANITY. 

2.  Accelerated  and  Retarded  Course  of  Ideas. 

If  an  accelerated  flow  of  ideas  takes  place,  as  in 
some  conditions  of  excitement,  the  overfilling  of  con- 
sciousness in  itself  leads  to  incoherency.  This  requires, 
however,  a  high  degree  of  acceleration  of  the  flow  of 
thought ;  in  moderate  degrees  the  combination  of  different 
series  of  thoughts  is  facilitated.  The  individuals  then 
become  more  brilliant  and  witty ;  the  successful  expression 
of  delicate  irony  and  the  ability  to  rhyme  easily  are  some- 
times found  in  such  cases.  But  when  the  concepts  follow 
one  another  so  rapidly  that  they  cannot  enter  their  suitable 
combinations,  a  wild  flight  of  ideas  is  developed.  In  the 
highest  degrees,  even  vigorous  external  impressions  are 
no  longer  able  to  restrain  the  hurrying  flood  of  ideas  for 
a  moment. 

Incoherency  may  also  arise  from  slowing  of  the  concepts 
and  their  combinations.  The  anxious  patient  becomes 
confused  because  his  thoughts  appear  slowly.  Confusion 
characterizes  conditions  of  mental  exhaustion  with  a  slow 
course  of  thought.  Sometimes  the  incoherency  is  only  ap- 
parent, if  aphasia,  due  to  a  definite  anatomical  lesion,  is 
present.  Another  result  of  the  slow  course  of  thought  is 
the  monotony  of  the  ideas.  The  violent  psychical  pain 
completely  fills  the  consciousness  of  the  melancholic 
patient,  and  allows  nothing  else  to  develop ;  the  march  of 
thought  sometimes  appears  to  stand  still  entirely,  and  only 
single  words  and  phrases  are  repeated  for  hours. 

The  insufficient  change  of  concepts  is  not  alwajTs  due 
to  their  slowness  of  succession,  but  occasionally  is  depend- 
ent on  their  long  duration.  This  disorder  is  often  ob- 
served, in  a  mild  form,  in  healthy  individuals ;  we  cannot 
escape  certain  notions,  "we  can't  get  rid  of  the  idea." 
This  is  especially  true  of  rhythmically  associated  groups 
of  ideas,  such  as  verses  and  melodies.  As  a  rule  these 
phenomena  disappear  rapidly,  at  the  most  in  a  few  days ; 
if  they  last  longer,  they  appear  to  us  to  be  morbid,  and  are 
associated  wi-th  disagreeable  feelings.     "  Gruebelsucht"  is 


IMPERATIVE   IDEAS.  71 

a  remarkable  clinical  form  of  this  disturbance.  The 
ideas  which  force  themselves  upon  consciousness  almost 
always  appear  in  the  shape  of  questions,  usually  of  a  reli- 
gious or  metaphysical  character.  This  disagreeable  feeling 
of  compulsion  is  also  common  to  imperative  conceptions 
which  appear  in  various  other  affections.  The  feeling  of 
compulsion  on  the  part  of  the  patient  must  be  emphasized 
because  this  alone  distinguishes  it  from  delusions.  Nu- 
merous patients  complain  that  they  cannot  get  rid  of  cer- 
tain annoying  thoughts  whose  folly  they  recognize,  and 
which  lead  them  to  commit  actions  which  they  find  laugh- 
able or  disgusting.  In  the  individual  cases,  the  contents 
of  the  imperative  conceptions  are  always  confined  to  a 
narrow  circle.  The  psychological  explanation  of  a  large 
number  of  these  imperative  conceptions  seems  to  be 
hinted  at  in  the  consideration  of  the  circumstance  that, 
in  our  mental  processes  in  general,  we  usually  employ 
comparison,  and  attempt  to  make  a  selection  among  an- 
tagonistic concepts. 

While,  in  this  play  of  question  and  answer,  the  healthy 
consciousness  at  first  shows  no  preference  among  the  nu- 
merous ideas  which  lie  ready  for  combination,  but  first 
compares  the  single  ones,  in  the  morbid  condition  an 
antagonistic  idea  enters  consciousness  with  imperative 
force.  Such  questions  are :  "  Why  is  the  moon  round  and 
not  square?"  or,  "Why  are  twice  two  four,  and  not  six?" 
or,  "  Why  is  not  the  stove  in  the  middle  of  the  room?"  Or 
the  question  refers  to  an  action  just  completed,  and  runs : 
"  Why  have  I  done  this,  and  would  not  the  opposite  have 
been  preferable?"  Or  an  individual  doubts  whether  he 
has  closed  the  door  properly  or  has  properly  addressed  a 
letter,  and  cannot  rid  himself  of  the  thought  even  after 
renewed  examination.  The  antithesis  of  the  present  situ- 
ation always  forces  itself  into  the  course  of  the  patient's 
thoughts :  on  a  tower,  he  thinks  of  jumping  down ;  near 
a  locomotive,  of  throwing  himself  in  front  of  it ;  in  an 
open  square,  of  the  dread  of  being  unable  to  pass.  In  the 
latter  cases  the  imperative  notion  may  be  favored  by  the 


72  HANDBOOK   OF   INSANITY. 

occurrence  of  vertigo.  Others  cannot  remain  in  closed 
rooms,  from  the  dread  that  some  accident,  such  as  fire, 
may  render  their  escape  impossible. 

But  the  imperative  conception  does  not  always  appear 
in  relation  to  an  antithesis;  it  often  originates  imme- 
diately and  directly,  and  is  not  found  in  the  shape  of  a 
question.  The  patient  occasionally  can  repress  the  de- 
veloping thought  before  it  pushes  itself  distinctly  into  con- 
sciousness. But  if  this  is  no  longer  possible,  and  the 
single  independent  concept  becomes  firmly  rooted,  a 
transition  is  furnished  to  the  stage  in  which  the  hitherto 
strange  notion  appears  natural  to  the  patient.  Previously 
he  had  attempted  to  correct  the  idea,  which  was  rec- 
ognized as  morbid,  by  all  other  ideas  at  his  command, 
but  now  this  single  one  becomes  the  fixed  point  around 
which  all  others  are  grouped,  and  thus  a  form  of  delusion 
develops. 

3.  Delusions. 

Delusions  are  false  judgments,  and  hence  closely  allied 
to  errors  in  their  development  and  contents.  Superstition 
shows  a  transition  between  delusions  and  error.  Common 
to  all  of  them  is  a  weakness  of  judgment,  which  is  either 
congenital  or  acquired.  Acquired  lack  of  judgment  char- 
acterizes delusions.  Every  healthy  individual  makes 
mistakes,  but  he  is  able  to  correct  them,  according  to  the 
degree  of  his  congenital  and  acquired  mental  abilities. 
Superstition,  as  a  result  of  education,  and  an  expression 
of  the  general  condition  of  culture  of  the  community,  is 
influenced  with  much  greater  difficulty;  but,  unlike  de- 
lusions, it  does  not  always  persist  against  all  opposition, 
as  a  firm  acquisition  of  the  diseased  brain.  We  must  as- 
sume a  disease  of  the  brain,  because  the  development  of  a 
delusion  is  either  associated  with  an  hallucination,  or 
can  only  be  explained  by  a  central  irritative  condition. 
According  as  the  connection  occurs  only  among  previous 
remembered  concepts  or  as  these  are  associated  with  new 
external  sensory  impressions,  delusions  exhibit  a  close  re- 


DELUSIONS.  73 

lationship  to  hallucinations  or  illusions.  A  false  judg- 
ment is  due,  however,  only  to  the  uncritical  acceptance  of 
the  combination  of  ideas  which  occupy  the  foreground, 
and  this  depends  on  some  morbid  condition  of  the  brain. 
Hence  a  certain  degree  of  mental  weakness  is  necessary  to 
the  development  of  delusions.  The  imperfect  comprehen- 
sion of  the  morbid  element  indicates  in  itself  the  weakness 
of  judgment,  and  this  is  not  found  in  imperative  concep- 
tions. The  more  frequently  and  vividly  hallucinations  de- 
velop in  a  brain,  particularly  when  several  sensory  tracts 
are  affected  at  the  same  time,  so  much  the  more  readily  is 
judgment  disturbed.  Even  when  the  hallucinations  sub- 
side, the  patient,  as  the  result  of  the  underlying  weakness 
of  judgment,  is  no  longer  able  to  escape  from  the  morbidly 
facilitated  concepts.  Here  his  own  personality  takes  part 
in  the  process.  The  disappearance  of  more  profound 
sympathy  for  others,  especially  for  members  of  his  own 
family,  is  one  of  the  most  certain  signs  of  the  beginning 
mental  weakness  which  accompanies  delusions.  When 
several  delusions  exist,  the  lack  of  judgment  is  generally 
so  great  that  the  patient  makes  the  most  contradictory 
statements,  and  his  previous  personality  appears  to  him  to 
be  entirely  changed.  If  the  power  of  judgment  is  more 
marked,  the  patient  generally  eludes  questions  concerning 
his  delusions,  whose  strange  character  still  astonishes  him 
somewhat.  Sometimes  he  makes  an  explanation  by  means 
of  comparison ;  for  example,  he  states  that  it  is  as  if  this 
or  that  sensation  is  produced  by  the  external  influence  of 
other  persons ;  more  frequently  he  simply  states  that  things 
are  as  he  says.  The  hallucination,  which  is  usually  un- 
derlying, is  so  vivid  that  the  connection  with  other  con- 
cepts of  former  experience  becomes  easy  to  his  impaired 
judgment  and  requires  no  explanation.  Delusions  which 
develop  directly,  without  hallucinations,  are  more  apt  to 
change  and  disappear. 

The  contents  of  delusions  are  as  manifold  as  the  ideas 
of  man.  Like  the  latter  they  are  associated  chiefly  with 
expression  by  means  of  language.      Hence   the   largest 


74  HANDBOOK   OP   INSANITY. 

number  are  based  upon  a  combination  with  such  auditory 
concepts  as  can  be  expressed  in  speech.  There  are 
important  clinical  differences,  however,  so  long  as  the 
mental  disturbance  is  in  process  of  development,  and  the 
chief  difference  in  their  contents  depends  upon  whether 
the  patient  is  in  a  cheerful  or  depressed  mood.  Numerous 
hypochondriacal  delusions  refer .  to  the  body  and  result 
from  disturbances  of  common  sensibility.  The  patient  is 
convinced  that  he  is  suffering  from  a  severe  disease  (dis- 
eases of  the  heart,  lungs,  spinal  cord,  genitals).  Some- 
times the  dreaded  disease  changes  or  several  diseases  are 
feared.  Sometimes  the  hypochondriacal  delusion  has  very 
strange  contents.  Headache  or  painful  sensations  in  gen- 
eral are  attributed  to  changes  in  the  brain.  The  patient 
then  feels  that  his  brain  has  dried  up  or  disappeared,  or 
has  undergone  some  other  peculiar  change.  One  patient 
was  convinced  that  the  posterior  parts  of  his  brain  were 
removed,  and  that  he  possessed  only  a  face  and  a  small 
part  of  the  brain.  Or  the  head  is  excavated,  and  the  brain 
replaced  by  a  sponge  or  a  bladder.  Still  more  varied  are 
the  delusions  which  are  associated  with  conditions  and  sen- 
sations in  the  digestive  organs.  The  mouth  and  anus  ap- 
pear closed ;  the  oesophagus  is  so  narrow  that  deglutition  is 
impossible.  The  stomach  is  filled  with  glass  and  pieces 
of  wood ;  the  food  is  retained  in  the  body  and  is  gradually 
deposited  beneath  the  skin.  Other  hypochondriacal  de- 
lusions develop  from  irritative  conditions  of  the  sexual 
apparatus,  especially  in  young  people  who  practise  mas- 
turbation. The  dread  of  being  impotent  prevents  the 
performance  of  coitus.  Sensations  in  the  skin  cause  re- 
peated washings  for  fear  of  having  been  made  unclean  by 
contact  with  some  object.  The  dread  of  finding  sharp 
objects  in  the  clothes  extends  to  other  objects,  and  a  so- 
called  fear  of  contact  develops.  As  various  organic  feel- 
ings often  combine  to  produce  hypochondriacal  delusions, 
the  notion  of  bodily  transformation  often  develops,  so  that. 
the  patient  thinks  he  is  bewitched  or  is  controlled  by  mag- 
netic machines.     In  the  highest  grades,  the  entire  body 


EXPANSIVE   DELUSIONS.  75 

appears  changed,  and  the  notion  develops  that  the  patient 
is  converted  into  an  animal. 

Delusions  very  often  assume  the  shape  of  ideas  of  per- 
secution, which  vary  according  to  the  predominant  affec- 
tion of  the  different  senses.  The  patients  taste  or  smell 
poison  in  the  food ;  gestures  or  remarks  of  others  are  in- 
terpreted as  inimical  influences.  The  tendency  to  refer  all 
events  to  their  own  personality  leads  them  to  find,  in 
letters  and  newspapers,  remarks  which  refer  to  themselves. 

Associated  with  these  conditions  is  the  delusion  of  hav- 
ing committed  sin,  which  is  one  of  the  most  constant 
symptoms  of  melancholic  forms  of  disease.  Many  believe 
they  have  committed  a  great  wrong  which  they  cannot 
describe  more  closely,  others  accuse  themselves  of  the 
most  fearful  crimes.  The  majority  dread  or  even  wish 
the  most  terrible  punishment  as  penalty  for  their  crimes. 

Unlike  the  depressive  delusions  just  mentioned,  there 
are  others  of  an  expansive  nature.  In  milder  degrees  they 
appear  merely  in  the  form  of  an  exaggerated  idea  of  the 
patient's  bodily  and  mental  abilities.  He  feels  able  to 
perform  great  feats  of  strength,  although  his  physical 
powers  may,  in  reality,  be  very  slight.  The  more  judg- 
ment is  lost,  the  greater  is  the  difficulty  experienced  by 
the  patient  in  recognizing  the  morbid  element  of  such 
notions.  While  the  maniacal  individual  still  retains  so 
much  judgment  that  he  remains  within  possible  bounds, 
the  feeble-minded  one  becomes,  in  periods  of .  excitement, 
unbounded  in  the  contents  of  his  delusions.  He  has  hun- 
dreds and  thousands  of  children,  he  is  Christ  or  God,  and 
speaks  all  the  languages  of  the  world.  He  claims  to  be 
physically  able  to  lift  the  universe.  And  yet  a  good  share 
of  these  claims  is  merely  boasting  and  fantasy.  Indeed, 
as  the  excitement  of  the  feeble-minded  subsides,  questions 
are  almost  always  necessary  in  order  to  lead  the  active 
play  of  the  fancy  into  the  production  of  expansive  ideas. 

Although  many  delusions  are  accompanied  by  corre- 
sponding feelings  and  moods,  antagonistic  moods  are  also 
observed  at  times,  and,  on  the  other  hand,  all  emotional 


76  HANDBOOK    OF    INSANITY. 

excitement  is  sometimes  absent.  This  occurs  both  in  con- 
valescent stages  and  in  the  beginning  of  terminal  dementia. 

If  a  high  degree  of  excitement  or  depression  is  no  longer 
present,  and  feeble-mindedness  has  not  yet  developed,  de- 
lusions may  appear  as  attempts  at  explanation  of  the  pa- 
tient's own  morbid  condition.  These  are  not  so  much  the 
results  of  hallucinations  present  at  the  time,  but  are 
trains  of  thought  which  appear  coincidently  with  the  hal- 
lucinations or  independently. 

The  following  fact  is  of  prime  importance  as  regards  the 
interpretation  of  the  development  and  course  of  delusions. 
In  patients  belonging  to  the  most  different  classes,  and  in 
all  parts  of  the  world,  we  always  find  certain  definite 
series  of  delusions  in  constant  repetition.  In  many  such 
series  of  ideas  persist  throughout  the  entire  course  of  the 
disease ;  they  are  called  fundamental  or  primordial.  Like 
central  hallucinations  and  imperative  concepts,  they  either 
develop  directly  in  the  diseased  brain  or  are  excited  by 
slight  external  impressions,  or  by  processes  within  the 
body.  The  latter  factor  requires  some  explanation.  In 
ordinary  health,  but  much  more  frequently  in  morbid  con- 
ditions, irradiated  sensations  in  the  body  are  often  associ- 
ated with  irritations  in  the  same  or  other  nerve  tracts.  For 
example,  auditory  impressions  often  produce  sensations  of 
light,  or  colors  give  rise  to  auditory  impressions.  In  such 
cases  of  irradiation  it  can  often  be  proved  that  the  origins 
of  both  nerves  lie  adjacent  to  one  another.  In  a  similar 
way  the  development  of  certain  delusions  is  connected  with 
sensations  located  in  adjacent  parts  of  the  brain.  But  as 
the  expression  in  speech  of  these  associated  sensations  al- 
ways revolves  within  very  narrow  circles,  the  contents  of 
the  associated  concepts  are  also  limited  by  certain  indi- 
vidual ideas  and  words,  and  these  recur  constantly  in  all 
individuals  after  the  same  internal  stimulus.  This  sheds 
light  on  the  uniformity  of  so  many  delusions  in  different 
individuals.  They  must  develop  in  certain  anatomical 
tracts,  and  find  expression  only  in  generally  known  terms 
of  speech. 


SYSTEMATIZATION   OF  DELUSIONS.  77 

It  is  only  after  long  duration  of  the  delusions  that  these 
become  associated  with  series  of  thoughts  due  to  logical 
inferences.  These  must  be  regarded  as  real  attempts 
at  explanation,  but  soon  become  part  of  a  regular  system 
of  delusions.  This  form  often  exhibits  a  very  uniform 
character  in  the  shape  of  so-called  querulous  insanity.  A 
patient  with  morbid  self-esteem,  who  has  suffered  some 
injury,  usually  well-merited,  acquires  the  notion  that 
bitter  injustice  has  been  done  to  him,  and  that  his  honor 
requires  him  to  fight  the  matter.  Accordingly  he  begins 
one  lawsuit  after  another,  and  sacrifices  home  and  fortune 
in  obedience  to  his  morbid  desire.  Of  course,  such  results 
only  follow  when  the  delusion  is  attended  by  a  certain  de- 
gree of  mental  weakness. 

Delusions  of  a  depressive  and  expansive  nature  are  not 
infrequently  associated  with  one  another.  The  persecuted 
individual  attributes  the  persecutions  to  his  own  assumed 
personal  superiority,  or  the  supposed  possessor  of  great 
wealth  thinks  this  is  kept  from  him  by  enemies.  In  these 
cases  one  concept  is  often  due  to  the  other  as  the  result  of 
an  attempt  at  explanation ;  in  this  way,  also,  fixed  delu- 
sions often  develop  after  the  morbid  condition  has  lasted 
a  long  time.  The  more  often  the  delusion  appears,  the 
more  readily  does  it  displace  antagonistic  concepts.  The 
interpretation  of  new  impressions  always  occurs  in  respect 
to  the  already  morbidly  changed  concepts,  and  so  com- 
pletely displaces  the  relation  of  the  patient's  personality 
to  the  outer  world,  that  he  thinks  he  has  become  a  differ- 
ent individual.  The  logical  manner  in  which  such  patients 
defend  their  delusions  is  often  astonishing ;  the  concepts 
have  been  accustomed  to  run  their  course  in  certain  logical 
forms  so  that  it  is  difficult  for  the  observer  to  detect  the 
flaw  in  the  first  links  of  the  series.  By  practice  in  de- 
fending their  delusions  the  patients  often  attain  such 
dialectic  skill  that  they  conceal  the  weak  points,  and  often 
deceive  even  judges.  The  patient's  relatives  often  believe 
that  he  has  such  and  such  a  fixed  idea,  but  that  he  is  other- 
wise sound  in  mind.    Careful  examination,  however,  shows 


78  HANDBOOK    OF    INSANITY. 

that  extensive  series  of  ideas  are  displaced  by  delusions, 
but  the  predominance  of  certain  ones  creates  the  impres- 
sion that  these  alone  are  present.  Mental  disorders  are 
always  complicated  and  are  never  confined  to  single  tracts. 
The'  very  impossibility  of  correcting  a  so-called  single 
fixed  idea  shows  a  want  of  judgment,  which  is  due  to 
mental  weakness. 

4.  Disorders  of  Memory  and  Fantasy. 

Among  the  combinations  of  concepts  in  general,  great 
importance  attaches,  in  regard  to  the  knowledge  of  insan- 
ity, to  those  in  which  the  mental  faculties,  known  as 
memory  and  fantasy,  are  involved.  Memory  is  a  primor- 
dial property  of  nerve  substance,  and  is  the  result  of  oft- 
repeated  impressions.  Although  we  do  not  understand 
the  psychoplrysics  of  this  process,  the  ability  to  recall 
ideas  is  a  fact  of  daily  experience.  All  concepts  are  con- 
veyed originally  through  the  senses.  Many  impressions 
may  be  retained  without  previous  apperception,  and 
appear  later  in  consciousness,  from  other  causes,  as  some- 
thing apparently  foreign ;  they  adhere  to  the  nerve-sub- 
stance and  form  involuntary  recollections.  Many  belong 
to  conscious  experiences,  and  then  can  be  renewed  volun- 
tarily. We  must  therefore  distinguish  a  memory  for  the 
recollection  of  concepts  and  for  their  renewal.  After 
periods  of  unconsciousness  the  ability  to  renew  impres- 
sions received  during  that  state  is  impaired,  but  these 
may  subsequently  enter  consciousness  and  be  remem- 
bered. In  the  voluntary  renewal  of  concepts  there  is, 
at  the  same  time,  a  reference  to  the  contents  of  con- 
sciousness, the  renewed  ideas  are  recognized,  and  re- 
ferred directly  to  the  past.  This  more  restricted  mem- 
ory occupies  a  higher  plane  than  the  unintentional  recur- 
rence of  concepts.  The  relation  and  combination  of 
remembered  concepts,  with  the  contents  of  former  experi- 
ence, are  utilized  particularly  by  the  group  of  ideas 
constituting  the  self -consciousness  of  the  individual's  own 
personality.     They  are  arranged  in  memory  as  a  con  tin- 


LOSS   OF   MEMORY.  79 

lied,  uninterrupted  series.  Only  the  most  recent  elements 
of  this  series  remain  as  complete  parts  of  memory,  further 
back  more  and  more  details  are  obliterated,  and  still  fur- 
ther back  only  a  few  recollections  remain.  This  renders 
possible  a  process  in  memory  which  is  called  localization 
in  time.  As  this  power  varies  greatly  in  healthy  indi- 
viduals, the  physiological  brain  formula  of  each  individual 
must  be  considered  in  examining  mental  disorders.  The 
organic  basis  of  memory,  the  cerebral  tissue,  does  not 
possess  the  faculty  of  retaining  impressions  iu  a  uniform 
manner,  so  that  the  power  of  voluntary  recollection — the 
other  side  of  memory — may  fall  into  the  background. 
This  is  especially  true  of  the  insane.  In  the  arrangement 
of  successive  concepts  so  many  links  of  the  chain  have 
disappeared,  that,  on  account  of  these  lacunae  in  memory, 
the  patient  has  no  unit  for  measuring  time. 

Patients  often  do  not  know  how  long  they  have  been  in 
the  asylum,  when  they  had  dinner ;  weeks  appear  to  them 
like  days,  years  like  months.  The  memory  of  recent 
events  is  first  lost,  and  finally  the  memories  of  childhood. 
The  memory  of  feelings  and  the  possibility  of  the  vigorous 
performance  of  actions  first  begins  to  diminish  after  the  loss 
of  the  memories  of  childhood.  This  is  explained  by  the  fact 
that  recent  events  adhere  more  loosely  to  the  nerve  substance 
and  cells,  while  those  which  have  been  repeated  for  years 
and  in  a  measure  have  become  organic  adhere  more  firmly.  . 
Feelings  are  more  inborn  and  are  more  the  expression  of 
organization  than  are  the  acquisitions  of  the  intellect,  and 
hence  they  adhere  longer  than  the  latter.  Finally,  the 
memory  of  the  mechanical  movements  necessary  for  the 
daily  wants  of  life  is  the  last  to  be  extinguished.  In 
some  cases  of  recovery  after  concussion  of  the  brain,  a 
restoration  of  memor3T  in  the  inverse  order  has  been 
observed. 

The  strength  of  adhesion  of  certain  concepts  depends 
not  alone  on  the  length  of  time  which  has  elapsed  since 
their  development,  but  also  on  the  character  of  the  special 
nerve  tissue  of  the  brain.      Memory  also   depends  very 


80  HANDBOOK   OF   INSANITY. 

materially  on  the  strength  of  the  impressions.  Hence  it 
is  evident  that  the  affections  of  memory  must  be  very 
manifold. 

One  of  the  most  common  disorders  in  daily  life  is  to 
forget  a  word,  which  is  "on  the  tip  of  the  tongue."  We 
may  even  have  a  notion  as  if  the  approaching  memory  is 
again  receding.  This  is  to  be  distinguished  from  weak- 
ness of  memory,  in  which  the  renewal  of  concepts  is  im- 
perfect or  entirely  absent,  because  the  organic  nervous 
substance  no  longer  contains  the  former  impressions.  On 
the  other  hand,  absent-mindedness  occurs  when  the  relation 
of  the  concepts  to  former  events  of  our  own  consciousness  is. 
disturbed.  The  latter  is  a  temporary,  functional  disorder, 
so  that  at  other  times  the  renewal  of  the  concepts  in  mem- 
ory is  easily  effected.  Forgetfulness,  which  forms  a  tran- 
sition to  the  weak  memory  of  old  age,  appears  to  depend 
more  upon  an  organic  basis.  In  old  age,  there  is  only  a 
passive  yielding  to  external  impressions  so  that  they  dis- 
appear rapidly  from  memory.  Finally,  the  old  man 
remembers  nothing  of  the  present,  while  his  vivid  recol- 
lection of  times  long  past  becomes  so  much  more  strik- 
ing. A  similar  condition  obtains  in  numerous  forms  of 
insanity,  particularly  those  associated  with  conditions  of 
weakness. 

Every  impairment  of  consciousness  interferes  with 
memory.  From  a  loss  of  memory  concerning  a  certain 
period  of  time,  we  infer  unconsciousness  during  that  pe- 
riod. In  the  impairment  of  consciousness  known  as 
"  daemmerzustand "  (dreamy  state,  literally  a  condition 
of  twilight),  the  capacity  of  remembering  events  which 
occurred  at  the  disappearance  of  consciousness  is  often  re- 
stored, but  the  impressions  adhere  feebly  and  the  remem- 
brance is  then  very  brief.  Immediately  after  the  act  an  epi- 
leptic may  say  distinctly  that  he  remembers  certain  details, 
but  at  the  subsequent  judicial  examination  these  have  disap- 
peared from  memory.  In  conditions  of  excitement,  like- 
wise, the  interpretation  of  the  surroundings  is  often  inac- 
curate so  that  the  memory  thereof  is  merely  summary,, 


LOSS   OF   MEMORY.  81 

and  does  not  go  into  details.  Conditions  of  exhaustion  of 
the  nervous  system,  for  example,  after  sexual  excesses, 
febrile  diseases,  etc.,  lead  temporarily  to  mental  enfeeble- 
ment,  during  which  the  reception  as  well  as  adhesion  of 
new  impressions  are  rendered  difficult  or  impossible.  Some 
patients  subsequently  remember  a  few  events  during  the 
period  of  mental  disturbance,  others  remember  absolutely 
nothing.  Thus  patients,  after  the  lapse  of  a  long  series 
of  years,  believe  that  they  are  still  at  the  same  age  as 
when  they  were  first  attacked.  In  these  cases  new  im- 
pressions during  the  period  of  sickness  have  not  become 
permanent  constituents  of  memory.  It  is  also  an  evidence 
of  the  imperfect  reception  of  concepts  in  the  memory  when 
patients  again  perform  the  same  acts  which  they  had 
hardly  finished,  or  tell  a  story  several  times  in  succession 
to  the  same  person.  This  is  generally  due  to  severe  affec- 
tions of  the  cortex.  At  the  same  time  the  renewal  of  old 
experiences  is  soon  confined  to  tracts  in  which  long  prac- 
tised habitual  concepts  are  found.  Even  in  imbecility 
teachers  retain  the  ability  of  repeating  the  rules  of  gram- 
mar, physicians  of  writing  prescriptions.  It  is  an  evidence 
of  great  mental  weakness  when  forgetfulness  in  these 
little  matters  occurs  in  daily  life,  and  is  not  noticed ;  for 
example,  if  an  accountant  makes  the  same  mistake  after 
repeated  calculations,  if  a  man  leaves  his  house  several 
times  and  forgets  to  close  the  door,  or  goes  out  without 
his  hat,  etc.  As  a  matter  of  course,  such  instances  of 
forgetfulness  are  morbid  only  when  frequently  repeated ; 
they  are  probably  due,  in  most  cases,  to  extensive  and 
deeply  spreading  diseases  of  the  brain. 

At  all  events  an  organic  basis  attaches  to  certain  defects 
of  memory,  which  are  characterized  by  the  loss  of  certain 
definite  groups  of  concepts ;  as  they  are  often  associated 
with  focal  diseases  of  the  brain,  they  are  so  much  less  rec- 
ognizable as  complete  psychoses.  They  include  so-called 
amnesic  aphasia,  disorders  of  writing-images,  etc.  In  a 
few  remarkable  cases  temporary  loss  of  a  single  foreign 
language,  of  numbers  and  the  former  musical  ability,  has 


82  HANDBOOK    OF   INSANITY. 

been  observed,  while  all  the  other  properties  of  memory 
remained  intact.  Hence  the  term  local  memories  has 
been  employed.  If  the  forgotten  powers  return  in  a  few 
days,  there  can  only  have  been  a  disorder  of  the  cerebral 
circulation  or  a  slight  mechanical  interruption  to  conduc- 
tion. After  a  concussion  of  the  brain,  a  surgeon  forgot 
that  he  had  a  wife  and  children,  while  in  other  respects 
his  memory  was  intact. 

Morbid  change  of  memory  may  also  be  manifested  by 
increased  reception  and  facilitated  renewal  of  memories. 
The  common  intensification  of  memory  in  children  finds 
its  counterpart  in  the  similar  ability  of  some  feeble-minded 
individuals,  although  in  the  latter  it  is  almost  always  one- 
sided. 

The  increased  reception  of  the  material  of  memory  de- 
pends very  materially  on  the  mood.  The  melancholic 
generally  notices  only  sombre  impressions  and  neglects 
cheerful  ones.  On  the  other  hand,  the  maniacal  individual 
manipulates  chiefly  the  cheerful  impressions,  and  associ- 
ates only  flattering  remarks  with  his  increased  self-esteem. 

The  insane  exhibit  notable  disturbances  in  the  truth  of 
their  memories ;  as  the  mood  of  the  moment  exercises  the 
greatest  influence  on  the  manner  in  which  memory-pictures 
are  conceived,  a  falsification  of  the  previous  impressions  is 
thus  produced.  Hence  his  entire  previous  life  appears  to 
the  melancholic  patient  as  a  chain  of  sad  experiences  and 
evil  deeds.  At  other  times  the  chief  factor  is  the  associ- 
ation of  the  contents  of  the  morbid  consciousness  with 
accidental  external  impressions.  The  deception  of  mem- 
ory is  then  shown  by  the  fact  that  the  patient  believes  he 
has  already  seen  persons  or  objects  in  his  vicinity.  A 
somewhat  similar  condition  is  that  in  which,  while  a  cer- 
tain situation  is  being  noticed,  the  impression  is  created 
as  if  the  same  situation  had  been  lived  through  before. 
Such  notions  are  very  fleeting  and  many  follow  one  another 
within  a  short  time.  At  first  the  individual  is  surprised 
by  the  impression,  and  seeks  for  the  completion  of  the  dis- 
agreeable unclearness  of  his  memory.      This  feeling  of 


DECEPTIONS   OF   MEMORY.  83 

•uncertainty  inhibits  the  voluntary  combination  of  the 
concepts  and  renders  nugatory  the  criticism  of  the  unusual 
contents  of  consciousness. 

Epileptics  exhibit  very  decided  deceptions  of  memory 
in  connection  with  the  attacks.  The  remembrance  of 
having  already  gone  through  the  same  experience  extends 
over  a  greater  period.  On  admission  to  the  asylum  the 
patient  states  not  alone  that  he  has  already  been  there, 
and  that  this  or  that  has  already  been  said  to  him,  but  all 
the  events  of  the  present  become  to  him  memories  of  the 
past.  This  deception  may  last  months  and  years,  and 
gives  rise,  in  the  patient,  to  the  notion  that  he  is  leading  a 
recurring  double  life.  In  this  way  poetical  fancies  con- 
firm the  belief  in  the  transmigration  of  souls.  When  the 
notion  of  double  life  appears  prominently  in  paroxysms,  it 
is  known  as  double  consciousness.  Here  the  renewal  of 
even  the  most  common  concepts  is  lost  for  days  or  months. 
If  the  old  condition  returns,  the  old  memories  return,  but 
those  belonging  to  the  recent,  almost  childish  condition, 
remain  wanting.  One  patient  narrated  during  the  next 
attack  the  things  that  had  occurred  to  her  during  the 
previous  one.  Similar  phenomena  are  also  observed  in 
periodical  insanity. 

The  disorders  of  memory  depend  mainly  upon  peculiar- 
ities in  the  course  and  combination  of  series  of  concepts 
which  are  in  themselves  independent,  and  stand  loosely 
associated.  An  allied  activity,  but  in  which,  at  first,  a 
voluntary  selection  completes  the  combination  according 
to  a  definite  plan,  is  that  faculty  known  as  fancy.  Its 
essential  characteristic  is  thinking  in  images,  while  the 
articulate  expression  of  more  sharply  defined  notions  is 
wanting.  Even  as  children  we  abandon  ourselves  to  the 
play  of  our  ideas;  the  adult  may  likewise  give  free  rein 
to  his  fancy.  It  takes  part  in  dreams,  and  it  is  prob- 
able that  vivid  fancies  and  dreams  are  very  often  mistaken 
for  hallucinations.  It  is  also  probable  that  hallucinations 
would  occupy  much  less  space  if  we  could  sharply  dis- 
tinguish them  from  the  notions  of  fancy.     The  latter  are 


84  HANDBOOK   OF   INSANITY. 

often  associated  with  bodily  sensations ;  the  hungry  indi- 
vidual dreams  of  feasts,  the  thirsty  one  of  delicious  drinks. 
In  the  hypochondriac  the  fancy  is  busy  in  depicting  fu- 
ture diseases.  The  melancholic  patient  associates  anxious 
feelings  with  notions  of  capital  punishment,  which  the 
fancy  paints  in  all  its  details.  The  patients  are  engaged 
in  building  a  world  of  fancy,  without,  however,  being  en- 
tirely convinced  of  its  reality.  Without  paying  any 
attention  to  those  around  him,  the  patient  makes  speeches, 
abandoning  himself,  like  an  actor,  to  the  situation  of  the 
moment.  He  walks  up  and  down,  and  has  a  lively  con- 
versation, so  that  it  would  appear  as  if  he  saw  or  heard 
imaginary  persons.  But  when  his  attention  is  attracted 
by  the  questions  of  the  observer,  he  interrupts  himself, 
smiling,  for  a  certain  length  of  time,  or  again  resumes  his 
harangue.  This  lively  play  of  fancy  entertains  the  pa- 
tient. It  occurs  particularly  during  conditions  of  excite- 
ment, and  after  recovery  the  patients  explain  that  they 
carried  on  conversations,  not  as  the  result  of  true  halluci- 
nations, but  that  the  vividly  excited  fancy  impelled  them  to 
utterance  in  speech.  Feeble-minded  patients  also  delight 
in  boastful  descriptions,  but  the  latter  result  mainly  from 
the  questions  asked  them  and  lack  the  creative  element  of 
fancy. 

C.    DISORDERS    OF   EMOTIONAL   LIFE. 

1.  Affects,  Sensual  and  Higher  Feelings. 

Acute  feelings  always  produce  changes  in  the  course  of 
our  concepts,  and  the  latter,  on  the  other  hand,  strengthen 
the  feelings.  Hence  we  call  them  affects.  As  a  rule, 
violent  feelings  suddenly  inhibit  the  flow  of  ideas; 
this  may  result  from  severe  pain  or  from  unexpected  sur- 
prises. It  is  only  after  the  cessation  of  the  affect,  as  a 
rule,  that  the  cause  appears,  and  then  fright,  wonder,  joy, 
or  anger  may  become  apparent.  Joyful  affects  subside 
more  rapidly  than  gloomy  ones,  which  have  a  tendency  to 
pass   into  permanent   moods.      By   means  of  numerous 


EMOTIONAL   DISORDERS.  85 

physical  sequelse  the  affect  reacts  upon  the  emotional 
excitement.  Angry  gestures  increase  anger,  palpitation 
increases  the  fear  of  the  timid  individual.  Finally  these 
sequelae  exhaust  the  affect ;  anger  wears  itself  out,  tears 
soothe  pain.  Otherwise  the  one  who  is  subject  to  an 
affect  loses,  when  he  is  no  longer  master  of  his  own 
movements,  the  mastery  over  his  own  feelings  and  ideas. 
Hence,  there  are  affective  conditions,  with  complete  con- 
fusion of  ideas,  which  are  distinguished  only  in  name 
from  a  maniacal  seizure.  Between  the  affects  of  healthy 
ndividuals  and  these  extreme  conditions  of  excitement 
there  is  an  entire  series  of  intermediate  conditions  which 
are  arbitrarily  called  healthy  or  morbid.  Nevertheless 
there  is  a  certain  average,  from  which  the  deviation  may 
not  be  too  great,  without  indicating  a  disproportion  be- 
tween the  degree  of  stimulus  and  the  excitement.  Sensa- 
tions and  feelings,  which  produce  pleasure  or  pain,  are 
sensory  subjective  feelings.  The  sum  of  all  feelings  which 
arise  from  the  sensations  of  our  own  body  constitute  com- 
mon sensation.  The  most  important  part  in  this  respect 
is  played  by  conditions  of  the  viscera,  but  sensations  in 
the  eye  and  ear  also  form  part  of  common  sensibility.  In 
higher  degrees  the  feelings  of  pleasure  or  pain  produced  by 
these  sensations  lead  to  increase  or  diminution  by  bodily 
movements  and  then  pass  into  impulses. 

But  the  disorders  of  impulse  fall  within  the  domain  of 
action,  while  for  the  present  we  confine  our  attention 
strictly  to  disturbances  of  emotional  life.  We  have  to  con- 
sider not  alone  the  disorders  arising  from  sensual  (in  the 
philosophical  sense)  feelings,  but  also,  and  to  a  greater 
extent,  those  arising  from  the  higher  mental  feelings,  i.  e. , 
all  emotional  movements  which  accompany  the  association 
of  ideas  and  the  mental  processes  attended  with  conscious 
selection. 

An  increase  of  the  feeling  of  pain  is  present  in  many 
mental  disorders.  All  stimuli  of  the  outer  world  and  of 
the  body  itself  then  increase  the  emotional  excitability ; 
even  the  stimulation  by  customary  impressions  becomes  a 


86  HANDBOOK    OF   INSANITY. 

source  of  painful  feelings.  This  is  observed  especially  at 
the  beginning  of  many  forms  of  insanity.  It  is  mainly 
a  sign  of  depressed  melancholic  conditions,  but  may  occur 
temporarily  in  cheerful  excitement.  The  term  psychical 
pain  has  been  applied  to  the  highest  degree  of  these  feelings. 
Such  conditions  are  distinguished  from  bodily  pain  only 
by  the  site  of  development.  Psychical  pain  is  a  result  of 
nutritive  disturbances  or  grosser  changes  in  the  brain, 
and  does  not  disappear  until  these  causes  are  removed. 
So  long  as  these  exist  it  occupies  the  foreground  of  con- 
sciousness, and  represses  all  other  feelings  and  ideas. 
In  slighter  grades  there  is  an  ill-defined  feeling  which  is 
manifested  as  restlessness,  anxiety,  or  sadness.  Out  of 
this  feeling,  which  forces  every  impression  into  the  same 
direction,  develops  the  sad  mood  in  which  sympathy  and 
love  excite  only  mistrust  and  hatred.  The  increased  sen- 
sibility brings  everything  into  relation  to  itself,  because 
it  is  really  affected  unpleasantly  by  everything.  Being 
distrustful,  the  patient  ascribes  his  condition  to  noxious 
influences  in  the  external  world,  considers  himself  perse- 
cuted, or  seeks  the  cause  of  his  malady  in  former  actions 
which  now  appear  sinful  to  him.  The  frequent  associa- 
tion with  hallucinations  increases  the  sensibility  and  con- 
firms the  resulting  delusions. 

The  combination  of  the  disturbance  of  bodily  "  sensual'* 
feelings  with  the  gloomy  contents  of  consciousness  de- 
presses the  self-esteem  and  produces,  as  a  rule,  a  vivid 
feeling  of  illness.  Another  result  of  the  inhibition  of 
the  flow  of  thought,  which  follows  the  predominance  of 
gloomy  notions,  is  the  restriction  of  thought  to  the  pa- 
tient's own  personality.  The  feeling  of  sympathy  for 
others  is  extinguished.  If  the  original  gloomy  affect  is  lost 
during  the  course  of  the  disease,  the  loss  of  sympathy  be- 
comes a  sign  of  mental  weakness  and  the  absence  of  all 
higher  psychical  feelings.  The  feeling  of  shame  is  also 
lost.  Hence,  even  a  diminution  of  the  painful  feelings  has 
set  in.  In  certain  congenital  conditions  of  feeble-minded- 
ness  the  feeling  of  shame  and  of  sympathy  for  others  is 


LOSS   OF   ETHICAL   FEELINGS.  87 

not  developed,  but  we  here  find  a  pronounced  egoism. 
The  lack  of  heart  and  tenderness  is  also  a  striking  symptom 
of  many  acquired  mental  diseases.  The  disappearance  of 
disgust  at  immoral  and  unsesthetic  actions  and  speech  is  also 
one  of  the  gravest  signs  in  the  development  of  the  disease. 
This  symptom  also  has  a  very  bad  prognostic  significance 
in  the  transition  into  mental  failure.  It  is  associated  with 
diminution  of  self-esteem.  In  some  conditions  of  excite- 
ment this  is  not  such  a  serious  matter.  But  if  a  patient, 
who  is  not  emotionally  excited,  does  not  hesitate  to  do 
indecent  things  in  the  presence  of  others,  it  constitutes  an 
evidence  of  great  mental  weakness  or  profound  disturb- 
ance of  consciousness.  The  absence  of  the  higher  mental 
feelings,  especially  religious,  ethical,  and  aesthetic,  their 
disappearance  or  imperfect  development  are  forms  of  the 
diminution  of  the  painful  feelings,  which  are  almost 
always  morbid.  A  special  form  in  this  category  is  a  part 
of  congenital  weak-mindedness,  and  is  often  called  moral 
insanity. 

The  last-mentioned  symptoms  may  also  be  attributed  to 
a  diminution  of  the  pleasurable  feelings.  If  the  patient 
loses  the  power  of  enjoyment  of  the  good  fortune  of  himself 
or  others,  or  if  pleasure  in  higher  things  is  restored,  these 
signs  are  important.  The  constant  feeling  of  illness,  de- 
pendent on  a  nutritive  disturbance  of  the  brain,  makes  it 
impossible  for  the  depressed  patient  to  feel  his  own  pleasure 
or  that  of  others.  A  fellow-feeling  may  be  impossible  on 
account  of  the  overfilling  of  consciousness  with  sad  or 
cheerful  concepts,  so  that  even  the  excited  patient  appears 
as  an  egoist. 

In  him  the  pleasurable  feelings  which  result  from  bodily 
sensations  have  undergone  a  marked  increase.  He  praises 
his  own  health,  declares  himself  capable  of  great  feats. 
At  the  same  time  the  course  of  other  combinations  of  ideas- 
is  facilitated.  Allied  to  this  condition  is  that  which  we 
have  already  described  under  the  term  ecstasy. 

By  the  alternation  and  mixture  of  disturbed  feelings 
of  pleasure  and  pain  are  produced  groups  of  symptoms 


88  HANDBOOK    OF   INSANITY. 

which  form  the  most  frequent  signs  of  mental  disease. 
When  there  is  increased  excitability  of  both  kinds  of 
feeling,  the  symptom  of  change  of  mood  appears. 

The  change  from  one  condition  to  its  opposite  takes 
place  with  rapidity.  The  unstable  equilibrium  is  deflected 
to  one  side  or  the  other  by  the  most  trifling  cause.  The 
fact  that  a  notion  of  the  uncertain  equilibrium  of  his  own 
mood  enters  the  patient's  consciousness,  results  in  irritable 
depression  and  uncertainty  of  action.  On  account  of  his 
irritability  *he  is  always  at  swords'  points  with  those 
around  him.  The  impulse  to  ward  off  all  external  in- 
fluences occupies  the  foreground.  In  epileptics  and  ine- 
briates these  conditions  are  dangerous  to  those  around 
the  patient. 

The  change  of  mood  is  sometimes  so  rapid  that  it  leads 
apparently  to  a  simultaneous  admixture  of  opjDosing  feel- 
ings. The  affect  of  pathos  exhibits  this  mixture,  and 
is  indicative  of  disease  unless  founded  in  the  previous  dis- 
position of  the  individual. 

The  temperament  of  the  individual  must  always  be 
taken  into  consideration;  it  influences  the  intensity  of 
emotional  excitement  and  the  rapidity  of  its  changes.  The 
choleric  and  melancholic  temperaments,  which  have  a 
tendency  to  strong  affects,  are  inclined  to  depressed  moods, 
while  the  sanguine  and  phlegmatic  temperaments,  with 
feebler  affects,  turn  rather  toward  the  enjoyments  of  life. 
On  the  other  hand;  the  temperaments  are  characterized 
either  by  a  rapid  or  slow  change  of  mood.  In  the  latter 
event  thoughts  are  apt  to  be  directed  toward  the  future. 
The  melancholic  individual  is  immersed  in  the  notion  of  a 
joyless  future ;  the  phlegmatic  individual  adheres  firmly  to 
his  notions.  Easily  moved  by  external  impressions,  the 
rapid  temperament  of  the  sanguine  and  choleric  is  fasci- 
nated by  the  present. 

In  another  group  of  disturbances  of  feeling  the  stimulus 
produces  the  antagonistic  feeling.  There  is  a  reversal  or, 
at  least,  a  complete  turn  in  the  connection  between  stim- 
ulus and  sensation.     We  may  here  mention  the  so-called 


TERROR.  89 

idiosyncrasies  of  hysterical  patients,  in  whom  sensations, 
such  as  odors  of  flowers,  which  are  agreeable  to  the  healthy, 
are  unpleasant,  while  nauseous  smells  produce  agreeable 
sensations.  This  is  indicated  not  infrequently  in  preg- 
nancy. A  practically  important  group  of  these  disorders 
is  found  in  the  domain  of  sexual  life.  Here  we  find  feel- 
ings of  dislike  against  the  opposite  sex,  of  love  for  the 
same  sex,  with  corresponding  desires  for  sexual  inter- 
course, usually  in  individuals  with  an  hereditary  taint. 
Such  individuals  are  generally  morbid  in  their  entire 
mental  development. 

The  higher  mental  feelings  may  also  suffer  reversal,  as 
shown  by  the  delight  taken  in  the  pain  experienced  by 
human  beings  and  animals,  by  the  criminal  tendencies  of 
the  feeble-minded,  etc.  These  qualities  usually  appear  in 
early  childhood,  and  thus  demonstrate  their  hereditary 
basis.  Similar  reversals  of  feelings  of  pleasure  and  pain 
may  also  appear  in  acquired,  non-hereditary  forms  of 
insanity. 

2.   Terror  and  Allied  Feelings. 

We  will  now  consider  a  disorder  of  feeling  which  is 
firmly  connected  with  definite  physical  signs.  The  affect 
of  terror  is  associated  intimately  with  disturbances  in  the 
action  of  the  heart  and  respiration,  and  also  of  the  secre- 
tory and  vasomotor  nerves.  For  this  reason  the  condition 
is  known  as  prsecordial  terror.  The  patient  experiences 
an  oppression,  a  pressure  in  the  region  of  the  heart  or  its 
immediate  vicinity.  He  feels  as  if  the  heart  were  com- 
pressed, as  if  a  weight  lay  upon  it,  or  as  if  the  chest  would 
burst.  Disturbances  of  respiration  lead  to  the  assertion 
that  the  windpipe  is  being  compressed.  The  sensations 
in  the  throat  and  heart  are  attended  with  incomplete  res- 
piration, and  with  acceleration  or  retardation  of  the  pulse. 
These  symptoms,  together  with  the  fact  of  the  psychical 
origin  of  terror,  compel  us  to  believe  that  disturbances  in 
the  cortex  radiate  into  the  pneumogastric  tract.  It  can 
only  be  attributed  to  actual  diseases  of  the  heart  or  lungs, 


90  HANDBOOK   OF  INSANITY. 

in  those  cases  in  which  such  diseases  are  actually  demon- 
strable, because,  as  a  general  thing,  the  origin  of  terror 
must  be  sought  in  the  central  nervous  system.  In  violent 
terror  there  is  almost  always  a  temporary  suppression, 
followed  shortly  by  increased  excretion  of  urine,  and 
also  of  perspiration.  All  these  physical  signs  also  occur 
constantly  in  normal  terror,  resulting  from  frightful  and 
gloomy  impressions.  In  the  terror  of  the  insane,  due  to 
hallucinations  and  delusions,  these  physical  elements  last 
for  a  longer  period.  But  after  the  prolonged  duration  of 
conditions  of  terror,  which  result  from  profound,  even 
anatomical  changes  in  the  cortex,  the  psychical  element 
becomes  more  prominent.  The  most  violent  conditions 
of  terror,  such  as  appear  in  epileptics  and  paralytics,  and 
in  which  there  is  often  a  profound  impairment  of  con- 
sciousness, are  often  attended  with  but  slight  implication 
of  respiration  and  the  heart's  action.  Some  insane  patients 
ascribe  the  feeling  of  oppression  to  the  head,  and  their 
terror  is  then  lacking  in  distinct  physical  signs.  In  other 
cases,  perhaps,  we  have  to  deal  with  milder  grades  of 
terror;  the  faint-heartedness  of  some  patients  probably 
depends  on  a  condition  of  mild  terror. 

As  in  all  affects,  so  in  that  of  terror,  contractions  and 
dilatations  of  the  vessels  play  a  decided  part.  It  may  be 
assumed  that  vasomotor  phenomena  run  their  course  in 
the  cortex  similar  to  those  which  are  observed  periphe- 
rally. As  very  many  forms  of  insanity  are  attended  by 
affects,  it  is  evident  that  changes  in  the  pulse  will  be  found 
in  them.  The  feel  and  the  sphygmograph  sometimes  dis- 
close a  peculiar  pulse  which  may  be  utilized  as  a  sign  of 
certain  forms  of  insanity.     Thus,  incurable  and  chronic 


Fig.  7. 


forms  exhibit  the  pulsus  tardus  (Fig.  7) ,  in  whose  sphyg- 
mogram  there  is  an  absence  of  the  rapidly  rising  top  of 


IMPULSIVE   MOVEMENTS.  91 

the  wave,  while  it  falls  without  any  secondary  elevations. 
This  is  an  evidence  of  paralysis  of  the  vessels.  The  dis- 
appearance of  the  elastic  tension  of  the  vessels  occurs  in 
those  forms  of  insanity  which  have  run  their  course,  and 
is  also  frequent  in  paralytic  dementia.  The  use  of  the 
sphygmograph,  however,  has  not  carried  us  very  far  in 
the  diagnosis  of  the  individual  clinical  forms  of  disease. 

D.    DISORDERS    OF    VOLITION   AND    ACTION. 

1.  Impulsive  Movements. 

We  have  described  impulse  as  the  real  element  of  all 
psychical  functions,  as  that  activity  in  which  sensation 
and  will  are  still  acting  in  their  original  combination.  In 
the  disturbances  of  emotional  life  we  studied,  in  part,  the 
clinical  significance  of  impulses;  we  will  now  consider 
their  relation  to  voluntary  acts.  It  is  important,  however, 
that  the  continued  predominance  of  accompanying  feel- 
ings and  sensations  over  clearly  volitional  acts  first  brings 
impulsive  life  into  appearance.  This  contrast  and  the 
predominance  of  feelings  over  volitional  acts  causes  the 
deviations  from  healthy  instinctive  life.  In  a  healthy 
consciousness  every  sensation  and  concept  is  accompanied 
by  feelings  which  arouse  a  desire  for  the  continuance  or 
for  a  change  of  the  existing  condition.  It  is  only  when 
these  feelings  attain  a  more  violent  degree  that  we  recog- 
nize them  as  an  impulse.  Under  certain  circumstances 
such  impulses  are  irresistible,  but  generally  we  overcome 
them. 

Among  the  morbid  impulses  we  first  mention  the  violent 
desire  to  use  the  muscles,  to  perform  movements,  i.e., bodily 
restlessness.  In  maniacal  conditions  it  is  manifested  by 
walking  about  restlessly,  striking,  shouting,  etc.  Very 
often  the  patient  does  not  intend  to  destroy  objects  or  mo- 
lest those  around  him,  but  merely  seeks  relief  of  his  over- 
flowing feelings.  Terror  and  frightful  ideas  may  give 
rise  to  acts  of  violence.  Slighter  grades  are  found  in  daily 
life  in  timid  and  anxious  people  who  perform  all  sorts  of 


92  HANDBOOK   OF   INSANITY. 

useless  movements,  pick  at  their  clothes,  change  their 
position,  etc.  In  morbid  increase  of  fear  we  find  aimless 
wandering  about  by  day  and  by  night,  constant  opening 
and  closing  of  the  windows,  dressing  and  undressing,  etc. 
There  is  also  great  restlessness  in  many  conditions  of 
mental  weakness,  which  leads  to  a  collection  of  all  con- 
ceivable objects.  In  the  development  of  recent  conditions 
of  excitement,  the  gradual  increase  of  this  impulse  may 
be  noted.  At  first  the  patient  is  merely  busy,  then  he 
walks  about  sometimes  for  hours,  and  exhibits  other  signs 
of  excitement.  At  the  height  of  the  disease  we  find  him 
shouting,  singing,  running  and  dancing,  tearing  his 
clothes ;  he  adorns  himself  with  rags  and  other  attain- 
able objects.  He  twists  bundles  of  straw  or  grass,  and  is 
continually  striking  about  him;  he  smears  the  walls  of 
the  room  with  faeces  and  washes  it  with  his  urine;  or 
he  scratches  the  walls,  and  destroys  the  doors  and  win- 
dows. In  the  highest  grades  of  excitement  the  general 
restlessness  is  increased  to  such  a  degree  that  it  is  diffi- 
cult to  understand  how  such  muscular  efforts  can  be  per- 
formed almost  without  interruption  by  an  often  feeble 
body.  The  maniac  has  no  feeling  of  exhaustion  because 
all  the  movements  are  performed  impulsively,  undisturbed 
by  voluntary  action.  Such  a  condition  may  develop 
without  coincident  hallucinations  or  delusions.  It  is 
plausible  to  assume  that  this  is  due  to  direct  irritation  in 
those  cortical  regions  which  have  accumulated  memory- 
pictures  of  movements. 

This  development  of  impulsive  movements,  apart  from 
every  influence  of  the  will,  is  shown  most  distinctly  in 
the  so-called  imperative  movements  of  demented  individ- 
uals. These  are  monotonous  movements,  which  recur 
regularly,  often  in  a  definite,  even  rhythmical  series. 
Originally  they  may  have  been  produced  in  great  part  by 
hallucinations  and  delusions,  but  after  the  disease  of  the 
brain  has  run  its  course  they  are  left  over  as  independent 
remains,  and  are  continued  as  a  matter  of  habit  after  their 
former  purpose  has  been  forgotten.     These  patients  are 


IMPERATIVE    ACTS.  93 

almost  always  wanting  in  the  ability  of  voluntary  selec- 
tion of  conscious  acts.  Some  of  them  rub  the  scalp  con- 
stantly, until  large  bald  spots  are  produced ;  others  grasp 
certain  parts  of  the  body,  for  example,  the  nose  and  ears, 
at  equal  intervals  in  a  certain  order.  When  disturbed, 
the  tempo  is  accelerated  and  the  movements  become  more 
violent,  without  losing  their  regularity.  Other  patients 
walk  rapidly  a  few  steps  forward,  then  one  backward  or 
to  the  side,  and  repeat  these  movements  innumerable 
times,  or  they  suddenly  rotate  a  few  times,  or  they  dance 
for  hours,  until  exhaustion  sets  in,  often  without  saying 
'a  word  or  making  any  other  manifestation. 

The  intervening  link  of  imperative  conceptions  often 
leads,  in  the  non-demented,  to  imperative  movements, 
which  often  appear  in  the  form  of  imperative  acts.  The 
notion  of  an  act,  which  has  pushed  itself  with  irresistible 
force  into  the  patient's  consciousness,  drives  him,  despite 
his  clear  insight,  to  the  most  terrible  deeds.  The  impul- 
sive character  is  shown  almost  constantly  by  the  accom- 
panying affect  of  fear.  These  distressing  conditions  lead 
to  acts  which  the  patient  abhors,  but  which  he  commits 
in  the  feeling  that  only  in  that  way  can  he  find  safety  and 
rest.  Suicide,  murder,  and  arson  are  acts  of  this  kind. 
Destruction  of  objects  may  also  take  place,  and  exposure 
of  the  person  and  similar  actions  are  also  observed. 
The  acts  are  usually  performed  rapidly  and  violently,  and 
are  brought  about  by  accidental  external  circumstances. 
The  sight  of  a  knife  or  club  rouses  the  conception  of  mur- 
der, and  the  terrible  deed  is  done  with  the  rapidity  of 
lightning.  An  indefinable  feeling  of  muscular  restless- 
ness sometimes  warns  the  patient,  and  he  then  adopts  pre- 
cautions or  begs  those  around  him  to  do  so.  Well-defined 
delusions  or  hallucinations  are  wanting. 

The  acts  of  violence  of  melancholia  are  related  to  the 
former  in  their  external  appearance;  the  violent  precor- 
dial fear  demands  relief.  An  hallucination  shortly  before 
the  deed,  especially  an  auditory  hallucination  in  the  shape 
of  brief   commands,  sometimes  intensifies  the   impulse. 


94  HANDBOOK   OF   INSANITY. 

After  the  act  has  been  committed  there  is  generally  a  feel- 
ing of  great  relief,  though  this  is  often  followed  by  a  feel- 
ing of  bitter  remorse. 

Impulsive  acts  also  occur  in  another  series  of  mental 
disorders,  in  which  there  is  either  congenital  for  acquired 
feeble-mindedness,  or  an  impairment  of  consciousness. 
Hysterical  and  epileptic  individuals  with  an  hereditary 
taint,  individuals  who  are  feeble-minded  from  youth,  pa- 
retics, or  patients  with  simple  forms  of  insanity  which 
have  run  their  course,  commit  fearful  self-mutilations, 
arson,  robbery,  without  any  clear  motive  or  distinctly 
conscious  concepts.  Even  after  the  deed  the  patient  is ' 
rarely  clear  concerning  it,  or  it  surprises  the  individual 
himself.  In  this  category  belong  some  cases  known  as 
impulsive  insanity.  A  proof  of  the  impulsive  origin  of 
these  conditions  is  the  remarkable  fact  that  they  occur  in 
paroxysms  with  intervals  of  many  years. 

Suicide  may  occur  in  the  insane  as  an  impulse.  This 
form  of  suicide  must  be  distinguished  from  several  others. 
If  an  excited  patient,  frightened  by  hallucinations,  jumps 
through  a  window,  or  into  a  river,  this  is  not  really  a  sui- 
cide, inasmuch  as  the  patient  has  attempted  to  avoid  a 
danger,  not  to  destroy  his  life.  Or  if  a  patient  takes  his 
life  with  the  view  of  pleasing  God,  it  cannot  be  regarded 
as  impulsive.  But  there  are  cases  in  which  the  patients 
have  an  irresistible  impulse  to  kill  themselves,  although 
they  struggle  against  it  with  a  clear  consciousness  and 
have  no  reasons  for  such  an  act.  In  certain  families  all 
the  members  succumb  to  this  fate,  and  usually  at  the 
same  period  of  life. 

In  the  same  way  impulsive  murder  in  the  insane  is  to 
be  distinguished  from  that  which  follows  delusions  or 
hallucinations,  and  in  which  the  patient  revenges  himself 
upon  his  supposed  persecutors  or  obeys  a  commanding 
"voice."  A  sudden  blind  impulse  may  seize  an  epileptic, 
who  cruelly  kills  his  victim  and  then  does  not  remember 
the  deed ;  or  a  patient  struggles  in  vain  against  the  fear- 
ful impulse  and  feels  free  only  after  the  deed  is  done. 


BOULIMIA.  95 

Arson  is  committed  by  some  feeble-minded  individuals, 
especially  at  the  period  of  puberty,  for  reasons  which  are 
obscure  to  themselves. 

In  certain  forms  of  imbecility  the  tendency  to  steal 
stands  on  the  same  level  as  the  already  mentioned  impulse 
to  accumulate  articles.  The  morbid  character  of  such 
impulses,  however,  is  only  determined  by  the  proof  of 
mental  disturbance  in  general,  which  is  also  manifested 
by  other  characteristics  of  the  entire  personality.  The 
single  impulse  is  merely  the  most  prominent  sign  and  is 
apt  to  force  the  others  into  the  background. 

Definite  forms  of  the  disease  are  shown  in  the  disorders 
of  individual  impulses.  First,  as  regards  the  desire  for 
food.  The  feeling  of  hunger  is  conveyed  through  the  ter- 
minations of  the  pneumogastric.  An  increased  desire  for 
food  and  drink  may  appear  without  previous  hunger  or 
thirst,  at  the  mere  sight  of  food,  or  immediately  after  a 
meal  there  is  an  unappeasable  feeling  of  hunger  which 
imperatively  requires  gratification,  but  is  often  relieved 
by  small  amounts  of  food;  or  large  amounts,  even  of 
indigestible  articles,  are  swallowed  ravenously.  Often 
the  articles  ingested  are  nauseating  to  healthy  indi- 
viduals, or  incredible  amounts  of  edible  articles  are  swal- 
lowed. In  the  latter  event  we  assume  a  defective  feeling 
of  satiety.  Other  forms  of  increased  hunger  are  based  on 
hallucinations  or  delusions,  but  the  disgusting  phenomenon 
of  eating  fseces  presupposes  a  profound  disturbance  of 
consciousnesss. 

Diminution  of  the  need  of  food,  as  part  of  a  complete 
mental  disorder,  is  almost  always  due  to  delusions  of  poi- 
soning or  hallucinations,  and  often  leads  to  complete  refusal 
to  take  food.  In  severe  affects,  there  is  often  an  inde- 
pendent loss  of  appetite,  with  or  without  coincident  gas- 
tric catarrh.  Continued  refusal  of  food  is  usually  favored 
by  a  secondary  gastric  catarrh,  or  the  general  weakness 
and  disturbance  of  the  nervous  functions  lead  to  imper- 
fect digestion,  and  this  in  turn  causes  diminished  appetite. 

The  longing  for  certain  articles  appears  in  the  insane 


96  HANDBOOK   OF   INSANITY. 

sometimes  as  a  desire  for  spices  or  strong  coffee  or  tea. 
Allied  to  this  is  the  desire  for  alcoholic  drinks.  One 
who  is  depressed  or  suffering  from  mild  melancholia 
takes  stimulants  in  order  to  cheer  up;  the  excited  in- 
dividual endeavors  to  conceal  his  internal  uncertainty 
by  alcoholic  excitement.  There  are  also  cases  in  which 
the  morbid  desire  appears  as  true  inebriety,  especially 
when  it  occurs  in  paroxysms  with  comparatively  free 
intervals.  The  impulse  to  drink  arises  from  an  acutely 
painful  feeling,  and  an  exhilarating  action  of  the  al- 
cohol is  not  attained  as  in  healthy  individuals.  The 
inebriate  is  not  fastidious  in  his  selection  of  stimulants. 
In  a  few  cases  they  drink  only  water  in  enormous 
amounts  if  alcohol  cannot  be  obtained.  The  drunken 
fit  lasts  a  few  days,  even  weeks.  The  chronic  symp- 
toms of  alcoholism  give  rise  to  variability  of  the  im- 
pulsive attacks,  with  a  rise  and  fall  of  all  the  symptoms. 
The  patient  attempts  to  relieve  disagreeable  sensations  by 
intoxication.  For  days  and  nights  he  lives  in  bar-rooms, 
unmindful  of  his  reputation  and  family.  As  a  rule,  the 
condition  is  suddenly  checked.  The  patient  grows  quiet, 
exhausted,  has  no  further  desire  for  drink,  and  gradually 
returns  to  his  previous  condition.  Some  experience  a 
decided  antipathy  to  alcohol  during  the  interparoxysmal 
periods.  A  certain  number  of  inebriates,  however,  are 
also  habitual  drinkers.  A  tendency,  however  slow,  to 
mental  weakness  is  unmistakable. 

Disorders  of  the  sexual  impulse  will  now  be  considered. 
Many  of  them  are  signs,  not  causes  of  mental  disturbance. 
In  healthy  individuals  the  sexual  passion  varies  greatly 
in  intensity,  so  that  it  becomes  difficult  to  decide  at  what 
stage  morbid  excess  begins.  It  is  to  be  considered  morbid 
when  the  sight  of  the  nude  in  art  produces  lascivious 
ideas.  In  many  insane  individuals,  especially  females, 
the  primary  psychosis  often  receives  a  special  coloring 
from  the  addition  of  a  morbidly  increased  sexual  desire. 
This  is  shown  by  the  expression  of  the  face,  the  constant 
talk  concerning  marriage  or  pregnancy,  or  the  desire  for  a 


SEXUAL   IRRITATION.  97 

uterine  examination.  Some  of  these  patients  manifest  un- 
usual cleanliness,  are  constantly  combing  the  hair  or  wash- 
ing the  body.  The  bounds  of  modesty  are  overstepped 
by  attending  to  the  wants  of  nature  in  the  presence  of 
the  physician,  or  by  carrying  around  the  night  vessel  as 
soon  as  he  appears.  Or  the  patients  suddenly  strip  them- 
selves on  seeing  a  man  and  offer  to  perform  coitus,  or  they 
lie  in  bed  and  imitate  sexual  intercourse  by  the  corre- 
sponding movements  of  the  body  and  face.  Still  more 
disgusting  is  the  tendency  of  these  patients  to  smear  fseces 
and  urine,  and  this  connection  of  disordered  sexual  sense 
and  olfactory  sense  reminds  us  of  the  clinical,  and  perhaps 
anatomical,  association  of  these  functions.  Sexually  ex- 
cited patients  often  have  distinct  olfactory  hallucinations. 
Special  odors  sometimes  give  rise  to  sexual  fancies.  The 
greatest  increase  of  this  disorder  leads  to  violent  assaults 
upon  men,  vile  and  abusive  language  being  employed  in 
order  to  conceal  the  true  feeling.  At  other  times  similar 
attacks  occur  as  the  result  of  annoying  feelings,  and 
these  conditions  must  be  sharply  differentiated.  The  term 
nymphomania,  applied  to  the  most  extreme  cases,  is  a  mis- 
nomer, because  the  condition  is  not  an  independent  disease 
of  the  sexual  sense. 

The  frequent  combination  of  religious  mysticism  with 
sexual  irritative  conditions  is  an  important  fact.  De- 
vout prayers  in  sexually  excited  individuals,  uninterrupted 
religious  exercises,  constant  reading  of  lives  of  the  saints, 
which  are  full  of  the  temptations  of  the  flesh,  the  occa- 
sional occurrence  of  the  most  terrible  orgies  in  certain 
revivals  show  the  causal  connection  and  clinical  relation- 
ship between  religious  fervor  and  sexual  desire.  The 
transmutation  of  the  sexually  colored  contents  of  con- 
sciousness into  firm  delusions  retains,  in  these  cases,  the 
striking  association  of  religious  and  sexual  elements ;  the 
patient  calls  herself  the  bride  of  Christ,  or  the  Virgin 
Mary.  This  combination  is  more  frequent  in  women,  but 
in  men  there  is  also  found  a  constant  association  of  relig- 
ious delusions  with  sexual  irritative  conditions  which, 
7 


98  HANDBOOK   OF   INSANITY. 

especially  on  an  epileptic  basis,  often  lead  to  severe  con- 
ditions of  excitement  attended  with  violence. 

Sexual  desire  may  also  diminish  in  insanity.  It  may 
be  entirely  absent  in  dementia,  and  is  occasionally  dimin- 
ished in  melancholia  or  conditions  of  exhaustion.  Dimin- 
ished sexual  desire  is  sometimes  a  sign  of  progressive 
disease  of  the  spinal  cord. 

The  character  of  the  sexual  sense  may  also  be  changed 
and  perverted.  Even  in  healthy  individuals  there  may 
be  temporary  peculiar  desires  in  this  respect ;  for  example, 
pregnant  women  attempt  to  bite  human  bodies,  excited 
men  are  tempted  in  this  way  by  little  girls.  Allied  to 
this  is  the  morbid  phenomenon  in  which  normal  intercourse 
is  followed  by  the  slaying  of  the  female.  The  impulse  to 
unnatural  sexual  gratification,  which  is  periodically  wide- 
spread among  rude,  and  also  among  excessively  cultured 
nations,  is  also  morbid.  At  the  present  time  pederasty  is 
almost  always  practised  either  by  those  who  are  satiated 
with  normal  intercourse  or  have  a  strong  hereditary  ten- 
dency to  nervous  diseases.  The  latter  group  of  cases  is 
decidedly  the  larger.  Public  and  boarding  schools  are  gen- 
erally the  breeding-places  of  this  vice.  It  is  remarkable 
that  there  is  sometimes  a  periodical  tendency  to  pederasty ; 
this  is  sometimes  due  to  an  epileptic  basis,  and  forms 
a  sort  of  substitute  for  an  epileptic  attack.  Finally, 
pederasty  is  sometimes  an  early  sign  of  paretic  dementia. 

There  is  another  category  described  under  the  term  con- 
trary sexual  sensations.  In  these  there  is  a  complete 
reversal  of  sexual  desire.  With  the  very  beginning  of 
sexual  desire  there  is  a  distinct  liking  for  persons  of  the 
same  sex,  those  of  the  opposite  sex  producing  in  the  pa- 
tient either  complete  apathy  or  even  disgust.  Ordinary 
attempts  at  intercourse  are  not  made  or  they  prove  fail- 
ures; then  follow  romantic  friendships  for  those  persons 
of  the  same  sex  who  disclose  similar  tendencies,  or,  at 
least,  permit  the  manifestations  of  the  perverse  love. 
Vigorous  sensual  feelings  and  pronounced  jealousy  are 
often  present.     There  is  often  a  tendency  to  assume  the 


SEXUAL   PERVERSIONS.  99 

walk  and  dress  of  the  opposite  sex.  For  example,  the 
male  patients  who  feel  themselves  like  women  prink 
themselves,  sway  the  body  at  the  hips,  and  assume  femi- 
nine habits  and  dress.  They  often  possess  all  the  defi- 
ciencies of  woman  without  any  of  the  attractive  qualities  of 
man.  Others  feel  clearly  that  their  impulses  are  opposed  to 
reason,  but  despite  violent  struggles  they  remain  the  slaves 
of  their  passion,  and  sometimes  end  in  suicide.  Great 
forensic  importance  attaches  to  some  cases  in  which  mur- 
der, attended  with  mutilation  and  even  with  devouring  of 
the  body,  formed  a  complete  substitute  for  sexual  inter- 
course. In  some  cases,  sexual  pleasure  is  produced  by 
wounding  the  skin  or  the  genitalia  with  a  knife. 

One  proof  of  the  morbid  character  of  such  impulses  is 
their  occasional  periodical  character.  The  patients  usu- 
ally feel  the  approach  of  the  attacks,  and  generally  make 
all  preparations  so  that  it  can  be  passed  through  as  easily 
as  possible.  In  the  intervals  they  are  good  husbands  and 
fathers,  and  gratify  their  unnatural  impulses  only  a  few 
times  in  the  course  of  a  year. 

Perversions  of  the  sexual  sense  are  also  observed  not 
infrequently  at  the  onset  of  senile  dementia.  Here  the 
patients  find  gratification  in  simple  exposure  of  the  per- 
son. Almost  all  forms  of  increased  sexual  desire  may 
also  occur  in  the  excited  stages  of  circular  insanity  and 
in  the  beginning  of  paralytic  dementia. 

A  general  feeling  of  indifference  leads  to  weakness  or 
even  complete  loss  of  volition.  The  loss  of  will  power  is 
especially  frequent  in  the  severe  forms  of  congenital  and 
acquired  dementia.  The  desire  for  food  excites  only  tem- 
porary, simple  movements,  and  even  these  are  sometimes 
entirely  absent.  Such  patients  must  then  be  fed,  and 
deglutition  only  begins  after  the  introduction  of  food  into 
the  buccal  cavity.  But  even  when  intelligence  is  rela- 
tively intact  and  independent  of  any  delusions,  abulia 
sometimes  occurs  in  certain  forms  of  mental  disturbance, 
especially  in  conditions  of  exhaustion.  These  patients  are 
very  readily  influenced,  and  not  infrequently  they  are  said 


100  HANDBOOK   OF   INSANITY. 

to  be  devoid  of  character,  although  a  morbid  condition  of 
the  brain  is  undeniable  on  careful  examination. 

2.  Expressive  Movements. 

Impulsive  and  volitional  movements  serve  as  the  ex- 
pression of  certain  conditions  of  consciousness.  Both 
forms  of  movement  are  not  separate  as  regards  observa- 
tion, and  actions,  which  are  generally  called  voluntary, 
are,  as  a  rule,  composed  of  both  kinds.  On  the  other  hand, 
volitional  actions,  by  becoming  gradually  imbedded  in 
memory,  are  converted  into  automatic  movements,  as  is 
shown  in  the  practice  of  all  complicated  movements  of  the 
body.  In  walking,  talking,  piano-playing,  etc.,  the  will 
has  first  executed  every  individual  movement,  but  later  it 
combines  the  most  complicated  movements  and  they  be- 
come more  and  more  automatic,  until  all  accompanying 
feelings  are  absent  and  an  almost  mechanical  process  re- 
sults. Hence,  many  acts  of  insane  with  impaired  con- 
sciousness appear  to  be  voluntary ;  the  association  of  the 
impulse  with  the  voluntary  movements,  due  to  the  function 
of  memory  of  the  brain  substance,  is  so  intimate  that  the 
boundary  between  the  two  is  apt  to  be  obliterated.  In 
addition,  the  accompanying  feelings  generally  determine 
the  strength  of  the  involuntary  and  voluntary  impulse  in 
consciousness.  In  this  struggle  of  impulse  and  conscious 
will  the  latter  is  often  overcome ;  this  is  clearly  shown  in 
the  general  forms  of  expressive  movements.  They  are 
one  of  the  chief  means  of  determining  emotional  excite- 
ment and  associated  psychical  disorders.  They  are  con- 
trolled in  a  measure  by  adults  and  healthy  individuals, 
but  children  and  insane,  especially  the  feeble-minded, 
clearly  show  the  condition  of  their  consciousness.  Their 
expressive  movements  are  not  voluntary,  but  follow  di- 
rectly the  underlying  affects  and  impulses.  The  pressure 
of  the  facial  muscles  leads  to  various  physiognomic  ex- 
pressions. The  character  of  the  mental  disorder  is 
shown  in  the  general  bearing  and  appearance  of  the  pa- 
tient.    Finally,  corresponding  expressions  are  manifested 


EXPRESSION   IN  MANIA   AND    MELANCHOLIA.         101 

by  the  timbre  of  the  voice.  In  many  cases  these  expressive 
movements  alone  permit  the  experienced  observer  to  form 
an  approximate  judgment  concerning  the  special  form  of 
disease. 

The  excited  patient  has  a  bold,  defiant  bearing,  his  eyes 
glisten,  he  speaks  loud  and  rapidly,  or  chatters,  laughs, 
and  sings.  His  movements  are  rapid  and  irregular,  and 
he  has  no  rest.  His  clothing  is  disordered,  dirty,  torn. 
He  adorns  himself  with  flowers,  feathers,  bits  of  paper, 
and  bright  metal ;  he  is  careless  of  his  personal  cleanliness. 

The  depressed  patient  sits  with  a  sad  expression,  staring 
in  silence ;  or  not  a  syllable  can  be  got  out  of  him,  and  he 
is  obstinately  mute  to  all  questions.  The  anxious,  excited 
patient  walks  about  restlessly,  wringing  his  hands,  and 
moaning  and  crying  aloud.  There  is  great  distortion  of 
the  features,  and  the  tearful  expression  sometimes  ap- 
proaches a  laughing  one.  In  children  and  women,  espe- 
cially in  hysteria,  one  affect  may  pass  immediately  into  the 
other,  but,  as  a  rule,  the  original  one  is  soon  resumed. 
This  is  also  true  of  the  insane.  Thus,  the  violent  laughter 
of  a  cheerfully  excited  patient,  which  was  attended  by 
violent  contractions  of  the  diaphragm,  is  suddenly  con- 
verted into  spasmodic  crying,  and  the  facial  expression  at 
the  same  time  shows  the  anxious  condition; 

When  the  emotional  conditions  have  subsided,  the  ex- 
pressive movements  often  assume  a  more  distinct  char- 
acter. Well  known  are  the  wrinkled,  suffering  features 
of  the  hypochondriac ;  the  swimming  eye  of  the  hysteric ; 
the  dignity,  proud  air,  and  arrogant  tone  of  the  patient 
suffering  from  delusions  of  grandeur.  It  must  be  re- 
membered, however,  that  other  considerations  are  often 
necessary  to  enable  us  to  arrive  at  a  conclusion.  Thus, 
profound  melancholy  may  lead  to  the  same  rigid  and 
indifferent  expression  as  advanced  imbecility. 

Many  cases  present  no  change  of  expression  to  super- 
ficial observation.  Finally,  there  is  no  doubt  that  the 
majority  of  asylum  patients  present  a  certain  similarity 
to  one  another  in  bearing,  expression,  and  general  appear- 


102  HANDBOOK    OF    INSANITY. 

ance,  after  the  affective  condition  has  run  its  course.  As 
a  matter  of  course,  this  is  not  marked  in  the  demented, 
who  are  unmindful  of  their  surroundings,  have  become 
callous  to  cold  and  heat,  rain  and  wind.  In  them  the 
similarity  of  expression  is  mainly  due  to  its  absence. 

A  peculiar  expression  is  furnished  by  patients  with 
hallucinations.  One  with  auditory  hallucinations  often 
listens  bent  over  forward,  or  he  closes  his  ears ;  he  often 
scolds  and  attempts  to  defend  himself  against  supposed 
complaints.  One  with  visual  hallucinations  looks  fixedly 
into  empty  space,  in  an  ecstatic  or  anxious  manner ;  the 
patients  with  olfactory  hallucinations  play  their  nostrils, 
hawk  and  spit  a  good  deal,  especially  as  gustatory  hallu- 
cinations are  likewise  often  present.  In  hallucinations  of 
feelings  there  are  numerous  gestures,  the  common  feature 
of  which  is  probably  the  attempt  to  ward  off  an  inimical 
influence. 

The  acts  of  the  insane,  as  the  result  of  delusions,  are 
also  very  manifold ;  mutilations  and  acts  of  violence  are 
especally  frequent. 

Finally,  we  must  again  consider  the  disorders  of  speech. 
The  language  of  gestures  has  been  discussed  in  the  pre- 
ceding remarks  on  movements  of  expression,  and  we  now 
turn  to  speech  in  the  ordinary  sense  of  the  word.  Like 
gestures,  articulate  speech  has  grown  out  of  the  impulse  to 
accompany  feelings  and  affects  with  movements  which 
stand  in  direct  relation  to  the  feeling-producing  impres- 
sions. It  is  true  that  all  senses  are  open  to  external 
impressions,  but  the  auditory  sense  in  particular  conveys 
the  expression  of  concepts,  sensations,  and  feelings  by  the 
production  of  tone  gestures.  But  these  are  merely  impulsive 
movements  of  expression,  and  speech  proper  only  develops 
when  the  intention  to  communicate  concepts  and  feelings 
to  others  is  present.  Language  is  developed  from  roots 
consisting  of  short  syllables.  An  abbreviated  repetition 
of  the  process  is  indicated  in  the  language  of  children,  but 
its  form  and  contents  are  then  produced  by  the  adults 
around  them  as  much  as  by  the  children  themselves.     In 


FORMATION   OF   NEW   WORDS.  103 

certain  forms  of  mental  disturbance,  in  the  retrogression 
of  the  faculties  to  a  childish  stage,  we  find  a  tendency  to 
form  new  words  out  of  simple  roots.  This  process  cannot 
be  analyzed  into  its  original  constituents,  viz.,  impulsive 
and  voluntary  expressive  movements,  because  the  adult 
patient  draws  a  great  part  of  the  new  material  from  the 
store  of  language  already  at  his  disposal.  Nevertheless, 
a  large  part  of  the  words  newly  formed  by  the  patient 
must  be  regarded  from  the  standpoint  of  the  original  ex- 
pressive movements,  although  there  are  also  other  condi- 
tions of  development.  A  confirmation  of  the  notion  that  the 
formation  of  such  words  is  allied  to  that  from  speech  roots 
is  found  in  the  circumstance  that  some  patients  employ 
monosyllabic  new  words  in  different  senses  by  displacing 
or  introducing  single  vowels  or  consonants. 

Another  method,  and  probably  much  more  frequent,  is 
the  development  of  new  words  through  hallu cinations.  The 
intimate  relations  between  speech  and  hearing  naturally 
point  especially  to  auditory  hallucinations.  As  an  expres- 
sion of  the  unity  of  thought  and  word,  human  speech, 
in  the  form  of  internal  speaking,  is  felt  even  by  the  insane. 
He  is  not  always  able  to  distinguish  between  the  morbid 
internal  voices  and  the  normal  speech  heard  internally ; 
often,  however,  he  recognizes  the  former  as  something 
foreign,  and  as  not  belonging  to  him,  although  it  comes 
from  within  him.  The  development  of  morbid  concepts 
from  peripheral  auditory  hallucinations  and  illusions  often 
finds  direct  expression  in  peculiar  phrases  and  words. 
If  the  vividness  of  the  auditory  hallucinations  is  not  over- 
powering, there  is  sometimes  a  chaotic  mixture  of  words, 
which,  in  cultured  patients,  may  appear  to  form  a  well- 
defined  language  by  the  addition  of  syllables  taken  from 
foreign  languages.  Such  speech  is  utterly  devoid  of 
meaning,  but  the  patient  often  defends  it  with  great  skill. 
Letters  and  treatises  may  be  composed  in  this  fashion. 
Such  language  is  always  an  indication  of  profound  dis- 
turbance and  advanced  mental  weakness.  But  it  must 
be  remembered  that  vivid  internal  hearing  accompanies 


104  HANDBOOK    OF    INSANITY. 

the  development  of  such  fantastically  formed  speech.  It 
is  unnecessary  to  assume  that  the  entire  process  is  always 
preceded  by  auditory  hallucinations,  but  in  the  majority 
of  cases,  the  insane  speech  notions  and  the  auditory  hallu- 
cinations develop  coincidently  on  the  same  diseased  basis. 
When  the  concepts  are  already  of  a  fearful  character,  the 
delusion  of  persecution  may  develop  in  connection  with  a 
suspiciously  sounding  word  or  noise,  and  these  processes 
at  once  find  articulate  expression  in  phrases  which  some- 
times exhibit  a  remarkable  similarity  in  different  patients. 
This  can  only  be  explained  by  the  similarity  of  the  mor- 
bid process.  On  the  other  hand,  such  great  differences 
are  also  noted  that  they  can  only  be  explained  by  bearing 
in  mind  the  individual  differences  in  the  predisposition, 
development,  and  education  of  the  brain  and  its  psychical 
functions. 

The  term  pseudaphasic  confusion  has  been  applied  to 
the  condition  in  which  incomplete  and  falsely  interpreted 
auditory  hallucinations  are  expressed  by  the  patient  in  a 
mutilated  or  falsely  understood  form.  The  new  words  or 
incomprehensible  word-structures  are  to  be  regarded  as 
the  remains  of  well-known  utterances.  This  condition  is 
also  associated  with  other  hallucinations,  but  at  all  events 
it  is  a  sign  of  severe  implication  of  the  brain.  In  a  certain 
measure  it  is  the  antithesis  of  the  flight  of  ideas  of  excited 
patients  in  whom  the  confusion  is  merely  an  expression  of 
the  facilitated  association  of  ideas,  while  a  disturbance  in 
the  formation  of  words  is  wanting. 

Echo-speech,  the  simple  repetition  of  words  just  heard, 
is  observed  in  dementia ;  all  comprehension  or  volition  on 
the  part  of  the  patient  is  wanting. 

A  peculiar  disorder  of  speech,  without  hallucinations 
or  delusions,  and  generally  distinguished  from  maniacal 
flight  of  ideas  by  the  absence  of  profound  affects,  is  the 
endless  reiteration  of  the  same  meaningless,  disconnected 
words,  in  the  form  of  a  speech  or  sermon.  This  is  known 
as  verbigeration ;  the  spasmodic  element  in  the  outbreak 
of  the  words  makes  the  term  speech-spasm  appear  suitable. 


VERBIGEKATION.  105 

It  would  seem  as  if  motor  inhibitions  must  be  overcome  by 
a  powerful  stimulus,  and  on  this  account  the  expression 
sometimes  becomes  pathetic.  This  distinguishes  verbi- 
geration, as  a  rule,  from  the  repetitions  of  words  due  to 
psychological  causes.  Verbigeration  may  also  be  observed 
in  letters. 

Finally,  speech  may  be  changed  voluntarily  on  account 
of  delusions.  Some  insane  speak  only  in  superlatives  and 
have  a  few  pet  expressions,  or  there  is  a  tendency  to  use 
only  diminutives,  so  that  the  speech  becomes  somewhat 
childish.  Another  peculiarity  is  the  frequent  repetition 
of  certain  words,  on  account  of  the  delusion  that  speech  is 
being  lost.  Sometimes  words  are  compounded  which  do 
not  belong  together. 

Aphasia  proper  will  be  discussed  in  the  section  on  de- 
mentia paralytica. 

Writing  also  furnishes  important  signs  of  mental  dis- 
ease. In  general  the  peculiarities  of  the  written  style 
correspond  to  those  of  speech,  although  some  patients, 
who  exhibit  undoubted  signs  of  insanity  in  every  speech, 
write  in  a  perfect,  apparently  normal  style.  It  must  be 
remembered  that  writing  is  always  learned  after  talking. 
Many  patients  control  themselves  in  conversation  so  that 
nothing  morbid  appears,  but  express  their  real  ideas  on 
paper.  In  writing  they  reveal  their  delusions  and  feelings 
much  more  readily  than  by  word  of  mouth. 

The  form  of  the  writing  is  also  an  important  aid, in 
diagnosis.  Childish  construction,  awkwardness,  and  ob- 
scurity of  expression  are  found  in  the  feeble-minded ;  the 
dement  writes  hardly  at  all.  The  melancholic  writes 
little ;  the  monotony  of  his  ideas  is  shown  in  the  constant 
repetition  of  the  same  complaints,  fears,  and  self-accusa- 
tions. The  characters  themselves  are  small,  occasionally 
tremulous;  there  is  little  difference  between  the  up  and 
down  strokes,  because  the  pressure  of  the  pen  is  feeble 
and  timid.  Excited  patients  write  a  good  deal,  and  in 
firm  characters.  The  writing  is  done  rapidly,  in  accord- 
ance with  the  accelerated  flow  of  ideas.     Finally,  the  hand 


106  HANDBOOK   OF   INSANITY. 

can  no  longer  keep  pace  with  the  ideas,  words  are  omitted, 
sentences  are  unfinished.  A  second  letter  is  often  written 
transversely  across  the  first,  and  all  the  corners  of  the 
paper  are  utilized.  The  paranoiac  makes  special  signs, 
and  all  sorts  of  flourishes.  He  underscores  a  good  deal, 
makes  exclamation  and  interrogation  points  without  rea- 
son. At  times  he  draws  and  scrawls.  Sometimes  he 
writes  single  words  in  Latin,  German,  and  even  Greek 
letters.  These  intentional  changes  in  the  writing  corre- 
spond, in  many  cases,  to  its  contents.  Certain  signs  cor- 
respond to  certain  delusions,  especially  by  the  addition  of 
certain  terminations.  Sometimes  the  patient  attempts  to 
write  the  smallest  possible,  almost  microscopic  characters. 
Such  writings  disclose  their  morbid  origin  at  once,  es- 
pecially if  they  contain  unintelligible  drawings  of  ma- 
chines, fabulous  animals,  or  symbolic  signs. 

In  dementia  paralytica  the  writing  constitutes  one  of 
the  most  important  signs.  Even  before  the  appearance  of 
other  symptoms  an  uncertain,  spasmodic,  tremulous  form 
of  the  letters  may  arouse  the  suspicion  of  the  development 
of  the  disease.  Some  letters  are  very  long,  others  small 
and  obscure.  Characteristic  of  the  advancing  disease  is 
the  omission  of  certain  letters  and  words,  or  poor  spelling, 
or  repetition  of  single  words  and  lines.  Many  erasures 
are  made,  and  the  second  attempt  is  even  worse  than  the 
first.  The  date  or  signature  may  be  forgotten,  while  en- 
tire sentences  may  be  copied  from  some  book  which  is 
lying  accidentally  near  the  writer.  The  paper  is  full  of 
blots,  the  letters  often  leave  the  ruled  lines.  The  commu- 
nication becomes  more  illegible  and  unintelligble  as  it 
approaches  the  conclusion. 

In  children  with  a  neuropathic  taint  who  have  become 
blind  or  deaf-mute  at  an  early  period,  and  in  idiots,  the 
letters  are  often  written  with  the  left  hand  in  the  direction 
from  right  to  left.  This  mirror  writing  is  rarely  done  by 
the  adult  insane,  probably  because  their  long  employment 
of  the  ordinary  direction  inhibits  a  tendency  to  the  wrong 
method. 


SENSORY   DISORDERS.  107 

E.    CONCOMITANT    PHYSICAL   SYMPTOMS. 

These  symptoms  are  often  elements  of  the  psychoses 
themselves,  not  alone  because  they  may  act  as  the  basis 
of  delusions  and  hallucinations,  and  are  part-causes  of  the 
disease,  but  because  they  indicate  the  point  of  attack  in 
the  treatment  of  the  disease. 

The  investigation  of  the  disorders  of  sensibility  in  the 
insane  is  difficult,  on  account  of  the  impairment  of  con- 
sciousness and  the  distrust  of  the  observer.  Complete 
absence  of  sensibility  to  pain  and  temperature  is  found,  in 
very  demented  individuals.  This  is  due,  as  a  rule,  to  the 
absence  of  a  reception  of  the  impressions  in  consciousness. 
The  patients  may  be  cut  or  burned  or  their  limbs  muti- 
lated, without  any  manifestation  of  pain.  Or  the  saliva 
drools  from  the  mouth,  flies  walk  about  the  face,  etc., 
without  an  attempt  on  their  part  to  prevent  it.  This  indif- 
ference can  only  be  understood  by  the  absence  of  all  atten- 
tion, and  cannot  be  regarded  as  a  peripheral  disturbance 
of  the  cutaneous  nerves.  This  is  also  true  of  self -muti- 
lations, such  as  castration,  tearing  out  the  eyeball  or 
tongue,  self-crucifixion.  Religious  delusions  in  particular 
enable  the  patient  to  bear  incredible  sufferings  in  silence. 
Peripheral  anaesthesias  may  also  occur,  but  they  are  usu- 
ally only  accidental  concomitants  of  the  psychosis.  They 
may  acquire  great  importance,  however,  by  being  converted 
into  delusions.  There  is  very  often,  at  first,  a  tendency  to 
describe  the  condition  allegorically.  Later,  the  explana- 
tion of  the  anaesthetic  condition  assumes  a  more  positive 
shape,  and  the  patient  states  that  the  affected  limb  is  made 
of  glass  or  wood.  If  there  is  very  extensive  diminution 
of  sensibility,  the  patient's  feeling  of  his  own  personality 
may  be  extinguished  and  he  believes  himself  dead.  If 
the  anaesthesia  is  confined  to  certain  viscera,  for  example, 
if  the  ingestion  of  food  takes  place  without  feeling,  the 
patient  believes  that  he  has  no  stomach.  If  the  anaes- 
thesias are  due  to  progressive  organic  affections  of  the 
brain,   feelings  of  disappearance  and  nothingness  are  es- 


108  HANDBOOK   OF   INSANITY. 

pecially  marked.  Perhaps  we  must  attribute  to  such 
anaesthesias  the  complaints  of  emptiness,  pressure,  band- 
like compression  of  the  head,  drying  of  the  brain,  air  and 
water  in  the  brain,  etc.  When  the  disease  extends  to  the 
spinal  cord,  the  parts  supplied  by  the  latter  become  in- 
volved. Anaesthesias  of  the  muscles  produce  numerous 
symptoms.  It  must  always  be  remembered,  however,  that 
psychical  insensibility  due  to  diminished  attention  suffices 
to  explain  such  anaesthesia.  Even  the  healthy  individual 
will  forget  pain  as  the  result  of  anger  or  excitement. 

Hypersesthesias  or  purely  quantitative  intensification  of 
normal  sensibility  are  not  frequent  in  psychoses.  But  if 
the  term  is  meant  to  include  qualitative  changes  arising 
from  the  combination  with  psychical  elements  and  alter- 
nation with  anaesthesias,  it  is  very  frequent.  The  attempt 
to  distinguish  a  peripheral  and  central  origin  is  not  very 
feasible,  because  cutaneous  and  muscular  sensibility  are 
chiefly  involved  and,  as  in  the  case  of  hallucinations,  these 
are  analyzed  with  difficulty.  But  experience  shows  that, 
in  not  a  few  cases,  circumscribed  hyperaesthesia  of  the 
skin  or  mucous  membranes  may  be  the  cause  of  some 
special  symptom  in  insanity.  The  integument  is  then 
rubbed  to  the  raw  by  the  patient.  Similar  symptoms  also 
depend  upon  diseases  of  the  cord,  especially  those  associ- 
ated with  the  sexual  apparatus.  It  is,  however,  impossi- 
ble to  determine  to  what  extent  peripheral  and  central 
elements  are  mingled  in  the  feelings  of  distressing  mus- 
cular restlessness,  pains  in  the  heart,  and  similar  condi- 
tions. In  hypochondria,  in  particular,  the  s}7mptomatology 
is  composed  of  a  mixture  of  peripheral  and  central  hyperaes- 
thesias.  In  this  disease  one  form  is  often  converted  into 
the  other.  An  originally  peripheral  hyperaesthesia  gives 
rise  to  psychical  hyperaesthesia,  and  this  gradually  becomes 
independent.  This  is  shown  most  distinctly  in  neuralgias 
associated  with  menstruation,  because  the  renewed  peri- 
pheral irritation  increases  the  psj^chical  irritability  already 
present,  and  sometimes  produces  a  periodical  recurrence 
of  secondary  delusions. 


BODILY    TEMPERATURE.  109 

The  temperature  of  the  body  undergoes  numerous 
changes.  Every  excitement  is  attended  by  a  rise  of  tem- 
perature, due  in  part  to  the  production  of  heat  attending 
the  increased  muscular  movements.  This  elevation  of 
temperature  is  marked  in  the  most  severe  forms  of  mania, 
and  in  epileptic  attacks,  but  it  is  then  due,  in  great  part, 
to  the  stimulation  of  certain  heat  centres.  In  motionless 
melancholies  and  dements  the  temperature  falls,  also  in  the 
exhaustion  after  conditions  of  excitement.  This  symptom 
can  best  be  combated  by  constant  rest  in  bed.  It  is  a 
peculiar  fact  that,  in  the  insane,  a  rise  of  temperature  is 
sometimes  absent  in  conditions  which  usually  give  rise  to 
fever.  For  example,  typhoid  fever  or  pneumonia  may 
run  an  almost  apyrexial  course.  Other  patients  have  a 
very  great  tendency  to  a  rise  of  temperature. 

Digestion  shows  the  most  notable  changes  among  all 
the  organic  functions.  It  is  usually  impaired  at  the  be- 
ginning of  all  psychoses.  In  melancholia  gastric  catarrh 
is  shown  by  anorexia  and  a  thick  yellow  coating  on  the 
tongue.  The  food  is  often  imperfectly  masticated,  the 
bolus  remains  in  the  mouth  for  a  long  time,  and,  if  not 
expectorafed,  finally  reaches  the  stomach  after  awkward 
movements  of  deglutition.  If,  in  addition  to  the  psychi- 
cal inattention,  there  is  also  paralysis  of  the  muscles  of 
deglutition,  the  patient  swallows  the  wrong  way,  and  at- 
tacks of  coughing,  pulmonary  inflammations,  or  almost 
instant  suffocation  may  result.  The  insane  suffer  not 
infrequently  from  spasms  of  deglutition  which  leads  to 
temporary  abstinence  from  food.  Excited  patients  swal- 
low forcibly  so  that  they  run  the  risk  of  impacting  firm 
particles  of  food.  If  paralyses  are  present,  even  the  in- 
gestion of  fluids  may  be  dangerous.  After  the  food  has 
entered  the  stomach,  it  may  resist  digestion  on  account  of 
its  imperfect  mastication.  Diarrhoea  frequently  results 
in  such  cases,  but,  as  a  general  thing,  the  insane  are  more 
apt  to  suffer  from  constipation.  The  excited  or  profoundly 
melancholic  patient  often  passes  an  evacuation  from  the 
bowels  without  noticing  it. 


110  HANDBOOK    OF    INSANITY. 

The  variations  in  the  weight  of  the  body  justify,  in  a 
measure,  the  assumption  that,  in  the  majority  of  cases, 
the  psychoses  are  the  expression  of  a  general  nutritive  dis- 
turbance of  the  entire  body.  On  the  other  hand,  it  is  also 
possible  that  the  disease  of  the  brain  is  the  immediate  cause 
of  the  change  in  weight.  As  a  rule  progressive  loss  of 
weight  accompanies  the  course  of  the  disease  to  its  climax. 
Remissions  are  attended  with  increased  exacerbations  with 
renewed  loss  of  weight.  This  sometimes  alternates  regu- 
larly in  the  periodical  and  circular  psychoses,  but  after  a 
while,  in  these  as  in  other  chronic  psychoses,  the  body 
adapts  itself  to  the  morbid  condition,  and  the  weight  re- 
mains uniform.  The  weight  almost  always  increases  in 
rapid  convalescence,  and  also  in  the  transition  to  terminal 
dementia.  Hence,  this  sign  is  favorable  only  when  there 
are  other  indications  of  mental  recovery.  The  greatest 
differences  in  weight  develop  very  rapidly  after  puerperal 
psychoses,  and  also  after  protracted  refusal  of  food. 

Another  series  of  nutritive  disturbances  are  due  to  pri- 
mary affections  of  the  central  nervous  organs  (congenital 
or  acquired)  and  may  be  grouped  together  as  disorders 
of  the  trophic  functions.  The  so-called  signs  of  degener- 
ation are  congenital  and  almost  always  hereditary.  The 
dwarfed  growth  of  some  idiots,  with  the  childlike  appear- 
ance, and  the  absence  of  hair  on  the  face  and  mons  ven- 
eris belong  to  this  category.  Disturbances  in  the  growth 
of  the  skull  must  often  be  explained  by  trophic  influences, 
at  all  events  the  mechanical  influences  attending  parturi- 
tion are  an  insufficient  explanation.  Among  the  malfor- 
mations of  the  skull,  visible  during  life,  we  must  mention 
a  disproportion  between  the  bones  of  the  cranium  and 
face,  and  unequal  development  of  the  two  halves  of  the 
face.  Further  signs  of  degeneration  (although  their  sig- 
nificance is  not  unquestioned)  are :  imperfect  position,  and 
inordinately  large  or  small  size  of  the  ears,  the  absence  of 
the  lobe  of  the  ear,  and  imperfect  development  of  the 
concha.  Greater  importance  attaches  to  irregularities  in 
the  position  and  development  of  the  teeth,  also  to  double 


HANDBOOK  OF  INSANITY. 


KIRCHHOFF. 


Ear   Plate. 


DESCRIPTION   OF  EAR   PLATE. 

The  two  adjacent  ears  represent  a  congenital  and  an  acquired 
malformation.  Among  the  numerous  congenital  malformations 
which  are  described  as  signs  of  degeneration,  a  very  frequent  one 
is  the  enlargement  and  overlapping  of  the  helix,  known  as  the 
"handle  ear." 

The  second  picture  shows  a  very  much  enlarged  ear,  which  is 
drawn  out  smoothly  in  an  upward  direction.  It  was  produced  by 
pulling  an  innumerable  number  of  times  upon  the  upper  rim. 
This  movement  was  one  of  a  series  of  imperative  movements,  and 
also  resulted  in  notable  atrophy  of  the  ear. 

Hsematoma  auris  (othaematoma)  is  found  usually,  as  upon  our 
picture,  in  the  scaphoid  fossa,  between  the  helix  and  antihelix, 
and  passes  through  the  concha  proper  more  or  less  close  to  the 
auditory  foramen.  It  usually  spares  the  tragus  and  antitragus. 
In  our  case  a  slight  perforation  of  the  tumor  had  occurred,  and  is 
recognizable  by  the  somewhat  semicircular  line  in  the  middle. 

In  the  ear  of  the  second  picture  marked  shrivelling  of  the  in- 
ternal auricular  cartilage  gradually  occurred  after  disappearance  of 
the  tumor.  This  acted  toward  the  middle  and  gave  rise  to  short- 
ening of  the  affected  parts  in  a  direction  radiating  toward  the 
auditory  foramen. 


SIGNS   OF   DEGENERATION.  Ill 

tows  of  teeth,  hare-lip  and  fissure  of  the  palate,  a  narrow 
vertical  or  excessively  flat  and  broad  palate  or  a  unilater- 
ally flattened  palate  may  also  be  mentioned.  Also  deflec- 
tion of  the  nose  or  the  palpebral  fissures.  The  latter 
are  occasionally  too  small  and  adherent  close  to  the  outer 
rim  of  the  cornea.  Other  signs  of  degeneration  are :  con- 
genital blindness,  disseminated  retinitis,  fissures  in  the 
iris,  albinism.  Other  parts  of  the  body  may  also  be 
affected,  but  we  will  mention  only  two,  viz.,  the  genital 
apparatus,  in  which  the  most  numerous  malformations 
are  observed,  and  secondly,  the  hair  on  the  body  (beard  in 
women,  unilateral  beard  in  men,  grayness  of  a  few  locks 
of  hair  in  childhood,  etc.).  One  or  more  of  these  signs 
may  be  found  in  an  individual,  but,  as  a  matter  of  course, 
a  single  one  possesses  little  significance.  Their  importance 
depends  upon  the  fact  that  they  indicate  hereditary  pre- 
disposition. 

The  second  group  of  trophic  disorders  develops  during 
disease  of  the  fully  grown  brain.  The  ear  of  the  insane 
sometimes  presents  a  tumor  (othematoma)  which  has 
long  been  the  subject  of  dispute.  At  first  it  is  a  circum- 
scribed tumor  of  the  concha,  usually  on  the  upper  and 
outer  parts ;  it  fluctuates  on  palpation,  and  is  bluish-red 
in  color.  It  develops  in  a  few  days,  remains  unchanged 
for  weeks  and  months,  and  disappears  gradually,  leaving 
a  deformed  concha.  It  is  due  to  an  extravasation  of  blood 
into  the  cartilage,  which  is  partially  ruptured.  During 
the  absorption  of  the  blood  the  ear  shrivels,  despite  thick- 
ening of  the  cartilage.  It  has  been  observed  in  rare  cases 
in  healthy  individuals,  without  any  history  of  injury  or 
hereditary  or  acquired  predisposition  to  insanity.  But,  as 
a  rule,  it  must  be  regarded  as  an  indication  of*  past  or 
threatening  insanity.  It  generally  occurs  in  severe  and 
advanced  stages,  in  which  other  vasomotor  disorders  are 
noticed.  If  such  a  patient  is  subjected  to  external  violence 
on  the  ear  (often  of  a  trifling  character)  the  othematoma 
develops.  But  both  factors  are  necessary,  viz.,  trauma- 
tism and  the  trophic  disorder  (brittleness  of  the  vessels) . 


112  HANDBOOK   OF   INSANITY. 

Corresponding  processes  are  observed  very  rarely  in  the 
nasal  cartilages. 

Another  trophic  disorder  is  brittleness  of  the  bones, 
attended  with  disappearance  of  the  lime  salts,  chiefly  in 
the  ribs  and  sternum.  An  increased  amount  of  lime  salts 
in  the  urine  has  also  been  observed.  The  destruction  often 
extends  to  the  cartilage,  which  is  converted  into  a  gelat- 
inous mass.  Trifling  violence  sometimes  breaks  several 
ribs.  In  one  case  a  slight  blow  with  a  hair-brush  frac- 
tured the  radius  in  a  paralytic  dement.  These  conditions 
often  heal  rapidly  at  the  beginning  of  a  psychosis,  but 
later  they  readily  undergo  suppuration. 

The  tendency  to  suppuration  in  vasomotor-trophic  dis- 
orders affects  particularly  the  subcutaneous  cellular  tissue. 
It  happens,  for  example,  that  paralytic  dements,  who  are 
kept  carefully  clean,  will  exhibit  an  elevation  of  the  epi- 
dermis, due  to  the  formation  of  a  vesicle,  upon  the  back, 
and  also  upon  parts  which  are  not  subject  to  pressure. 
When  this  takes  place  on  the  back  a  bed-sore  is  apt  to 
form  in  a  few  hours.  This  suppurates,  and  after  slow  ex- 
foliation of  the  skin  and  shreds  of  tissue,  shows  how  deeply 
the  destruction  has  taken  place.  Under  careful  treatment 
recovery  is  possible.  In  other  cases  a  phlegmonous  process 
develops  within  a  few  days,  gangrene  of  the  cellular  tis- 
sue takes  place,  with  infiltration  of  pus  between  the  mus- 
cles, febrile  movement,  and  rapid  death.  A  proof  that 
such  acute  decubitus  depends  essentially  on  paralysis  and 
fragility  of  the  vessels,  and  that  trauma  is  only  an  exciting 
cause,  is  found  in  the  fact  that  it  occurs  also  in  paralytic 
dements  who  are  not  paralyzed,  but  are  constantly  run- 
ning about  and  lie  down  only  for  a  few  moments.  Like 
othcematoma,  acute  decubitus  is  an  evidence  of  an  incura- 
ble psychosis. 

The  secretion  of  tears,  like  other  secretions,  is  often 
very  slight  in  cases  of  melancholia.  It  is  only  in  begin- 
ning recovery  after  profound  melancholy  that  tears  again 
appear,  and  they  then  exercise  a  soothing  effect.     When. 


SALIVARY   CHANGES.  113 

there  is  a  rapid  change  of  mood  in  feeble-minded  patients, 
tears  are  apt  to  come  and  go. 

In  all  depressed  conditions  the  secretion  of  saliva  appears 
to  be  diminished.  Whether  an  increase  constantly  ac- 
companies conditions  of  excitement  is  not  certain,  but,  at 
all  events,  this  happens  occasionally.  The  secretion  may 
be  the  result  of  increased  movements  of  the  mouth,  as  in 
constant  speaking,  or  the  .  saliva  may  be  secreted  volun- 
tarily, in  order  to  be  smeared  on  walls,  anointed  upon  the 
body,  etc.  Some  perfectly  quiet  demented  patients  expec- 
torate freely  in  a  skilful  manner,  others  employ  it  as  a 
convenient  means  of  defence  against  annoying  approach. 
Sometimes  the  patients  expectorate  enormous  quantities, 
especially  when  gustatory  and  olfactory  hallucinations 
lead  them  to  cast  out,  with  the  saliva,  poisonous  elements 
from  the  body.  When  stuporous  patients,  with  the  body 
bent  over  forward,  allow  saliva  to  run  out  of  the  angles 
of  the  mouth,  so  that  their  clothes  are  constantly  wet,  this 
ptyalism  is  not  necessarily  due  to  morbid  increase  of  saliva. 
The  normal  amount  of  saliva  secreted  is  very  large,  and 
in  individual  cases  it  is  difficult  to  determine  whether  it 
is  really  excessive. 

Although  examination  of  the  urine  is  difficult  in  the 
insane,  certain  changes  appear  to  be  found  regularly  in 
psychical  disturbances.  In  all  conditions  of  depression 
the  amount  of  urine  is  very  slight,  and  vice  versa 
in  conditions  of  excitement.  In  some  hysterical  cases 
there  is  almost  complete  suppression.  As  a  general 
thing  the  amount  of  phosphates  is  diminished,  but  cases 
have  also  been  reported  in  which  they  were  present  in  ex- 
cess. In  periodical  mania  sugar  has  been  found  occasion- 
ally in  the  urine,  but  in  some  of  these  cases  slight  diabetes 
was  also  present  between  the  attacks.  Albumin,  occa- 
sionally even  a  few  casts  and  blood-cells,  have  been  found 
in  the  various  forms  of  spasmodic  attacks  observed  in  the 
insane. 


IV. 

THE  COURSE  OF  MENTAL  DISORDERS. 
A.    COURSE,  DURATION,  AND    TERMINATIONS. 

The  boundary  between  disease  and  healtli  is  not  sharply 
defined,  so  that  we  are  not  always  able  to  tell  when  the 
physiological  limits  are  exceeded.  The  observation  of  a 
large  number  of  individuals  furnishes  us  with  average 
types,  but  even  among  these  there  are  certain  psychical 
conditions  of  healthy  life  which  are  subject  to  great  alter- 
nations and  yet  do  not  constitute  the  forerunners  of  morbid 
processes. 

We  may  distinguish  between  morbid  conditions  and 
processes.  The  former  are  not  always  terminal  states  of 
diseases  which  have  run  their  course,  but  may  also  be  con- 
genital. They  are  permanent,  while  morbid  processes 
exhibit  a  progressive  tendency.  This  difference  is  some- 
times obliterated  by  the  fact  that  the  mental  disorder  runs 
a  very  slow  course,  and  thus  simulates  a  morbid  condition. 
Healthy  psychical  life  also  has  a  slow  development ;  hence, 
the  process  of  life  itself  may  bring  with  it  the  morbid 
process;  this  special  process  is  known  as  degeneration. 

The  beginning  of  the  disease,  whether  it  develops  out 
of  an  already  existing  congenital  condition  or  out  of  com- 
plete health,  is  difficult  to  determine,  especially  on  account 
of  the  usually  slow  development  of  the  disease.  It  is  al- 
most exclusively  in  cases  with  an  hereditary  taint  that 
the  symptoms  sometimes  break  out  with  sudden  violence. 
But,  as  a  rule,  the  disease  begins  gradually  and  is  attended 
with  prodromata. 

The  first  changes  occur  mainly  in  the  finer  movements 
of  emotional  life,  in  morals  and  character.     The  tastes, 

114 


PRODROMATA.  115 

habits,  and  desires  of  the  patients  change ;  they  are  in  an 
excited  or  depressed,  often  in  a  changeable  or  irritable 
mood.  They  suffer  from  an  indefinable  feeling  of  illness. 
This  gradually  increases,  the  patient  becomes  timid  and 
has  a  presentiment  of  the  impending  loss  of  reason.  There 
may  also  be  sudden  attacks  of  desperation,  and  at  times  a 
tendency  to  suicide.  The  facial  expression  and  the  ges- 
tures undergo  a  change.  There  is  an  irresistible  tendency 
to  movement,  to  wander  restlessly  to  and  fro,  without 
finding  rest  or  comfort ;  or  they  complain  and  exaggerate 
their  sufferings.  They  complain  that  their  ideas  have 
disappeared,  that  they  will  never  be  well,  and  that  death 
is  inevitable.  Others  complain  of  the  loss  of  memory,  their 
ideas  are  concentrated  more  and  more  upon  their  own  ail- 
ment, and  excessive  egoism  develops.  For  weeks,  months, 
and  even  years  these  prodromata,  in  the  shape  of  absent- 
mindedness,  indifference,  or  striking  activity,  may  pre- 
cede the  outbreak  of  the  disease  proper.  At  a  later  period 
physical  disorders  are  added  to  these  mental  phenomena. 
Among  the  most  important  is  disturbed  sleep  and  fright- 
ful dreams.  Headache  and  dizziness  are  often  distressing 
symptoms.  The  appetite  is  lost,  digestion  becomes  im- 
paired, obstinate  constipation  develops,  and  often  there  is 
a  sudden  rapid  emaciation.  The  observation  of  these 
prodromata  is  of  the  greatest  importance,  because  their 
treatment  offers  the  possibility  of  preventing  the  psycho- 
sis. As  a  rule,  the  observations  of  the  patient's  family 
concerning  the  period  at  which  these  changes  begin  are 
entirely  unreliable.  The  most  striking  symptom  to  the 
laity  is  the  gradual  change  in  the  character.  Later 
prodromata  may  consist  of  a  feeling  of  delayed  and  im- 
peded thought  and  imperative  notions.  The  special 
character  of  the  psychosis  can  rarely  be  predicted  from 
the  prodromata,  although  the  subsequent  condition  of 
depression  or  exaltation  often  has  its  corresponding  pre- 
cursors. 

When  the  severe  organic  forms  of  insanity,  particularly 
dementia  paralytica,  develop,  the  prodromata  often  have 


116  HANDBOOK   OF   INSANITY. 

a  different  character.  There  are  early  signs  of  mental 
weakness;  mental  exhaustion  soon  occurs,  the  lapses  of 
memory  are  very  striking.  The  reception  of  new  impres- 
sions is  slow;  there  is  diminution  or  even  complete  loss  of 
the  ethical  feelings.  On  account  of  the  transgression  of 
criminal  laws,  the  eyes  of  the  family  are  often  opened 
earlier  in  these  cases,  especially  when  the  patient's  cir- 
cumstances do  not  explain  his  thefts,  wastefulness,  or  sex- 
ual offences.  Finally,  the  suspicion  becomes  confirmed 
when  motor  disorders  develop,  especially  in  speech  and 
the  facial  muscles.  In  some  who  are  about  to  become 
paralytic  dements  there  is  occasionally  a  great  increase 
in  mental  activity  without  other  disturbance  or  weakness 
of  the  mental  functions.  They  are  enterprising  and  man- 
ifest abilities  which  they  had  not  possessed  before,  and 
act  in  an  entirely  different  manner  from  their  previous 
habits.  This  change  of  character  is  more  striking  than 
in  the  prodromal  stage  of  other  conditions  of  excitement. 

The  onset  of  the  mental  disorder  proper  is  either  gradual 
or  sudden.  The  majority  of  those  forms  which  run  a  rapid 
course,  such  as  febrile  and  postfebrile  psychoses,  insanity 
of  parturient  and  puerperal  women,  and  insanity  after 
violent  emotions,  injuries  to  the  skull,  attempts  at  hang- 
ing, and  carbonic-oxide  poisoning,  have  a  sudden  onset. 
They  also  run  a  rapid  course,  attended  with  violent  symp- 
toms. These  psychoses  are  also  characterized  by  the  sud- 
den cessation  of  the  attack,  with  immediate  restoration  of 
the  former  mental  condition.  Such  conditions  have  been 
described  as  transitory  insanity.  A  characteristic  feature 
is  the  profound  disturbance  of  consciousness  during  the 
entire  attack,  with  subsequent  marked  hiatus  of  memory. 
This,  like  the  other  severe  irritative  symptoms  (hallucina- 
tions, fear,  psychomotor  irritative  processes) ,  depend  upon 
circulatory  changes.  Some  of  these  cases  may  even  run 
their  course  in  a  few  hours,  and  then,  as  a  rule,  terminate 
in  recovery  after  a  deep  sleep,  followed  by  a  complete 
hiatus  of  memory  concerning  the  attack.  They  offer  a 
favorable   prognosis,   inasmuch  as  they  usually  recover 


REMISSIONS.  117 

rapidly  and  completely.  This  is  also  true  of  pathological 
affective  conditions  and  alcoholic  excesses. 

The  slowly  developing  psychoses  often  run  a  slow  course, 
attended  by  the  development  of  delusions  and  hallucina- 
tions. After  they  have  reached  their  culminating  point, 
they  may  remain  in  that  state  for  a  long  time.  But,  as  a 
rule,  there  is  soon  a  diminution  in  the  severity  of  the 
symptoms,  or  even  a  remission  or  intermission.  These 
changes  are  especially  marked  so  long  as  the  disorder  is 
still  attended  by  affects.  It  is  a  matter  of  practical  im- 
portance that  such  remissions  usually  follow  a  change  of 
surroundings  or  locality,  but  are  soon  followed  by  a  fresh 
exacerbation.  When  the  symptoms  disappear  entirely 
during  the  intervals,  we  speak  of  lucid  intervals. 

Many  external  influences  may  give  rise  to  remissions 
during  chronic  psychoses.  The  symptoms  are  sometimes 
intensified  in  spring  and  improved  in  autumn.  Excessive 
heat  and  cold  may  act  in  a  similar  way. 

The  remissions  are  sometimes  so  complete  that  they 
may  deceive  us  concerning  the  duration  of  the  disease. 
At  such  times  many  chronic  patients  possess  so  much  self- 
control  as  to  conceal  their  delusions  entirely.  Some 
maniacs  cease  to  talk  irrationally  so  that  we  might  look 
for  recovery,  did  not  their  indifference  to  outside  interests, 
the  lack  of  sleep  and  of  other  favorable  bodily  conditions, 
show  that  recovery  was  still  remote.  Certain  melancholies 
may  conceal  their  insanity  and  their  impulse  to  commit 
suicide  until  the  very  day  on  which  they  reach  their  end. 

These  remissions  may  last  from  a  few  hours  to  several 
years.  The  remissions  are  more  prolonged  the  more 
chronic  the  mental  disorder,  and  the  less  the  hopes  of  com- 
plete recovery.  Lucid  intervals  may  last  days,  weeks,  or 
months. 

There  is  also  an  important  class  of  psychoses  in  which 
a  regular  alternation  of  morbid  and  comparatively  healthy 
conditions  is  typical  and  characteristic  (periodical  psycho- 
ses) .  The  different  periods  may  last  days,  weeks,  months, 
or  even  a  number  of  years,  but  even  in  the  intervals  the 


118  HANDBOOK    OF   INSANITY. 

patients  may  not  be  regarded  as  mentally  sound.  This 
class  is  subdivided  into  two  groups,  viz.,  periodical  psy- 
choses proper,  and  cyclical  or  circular  psychoses.  In  the 
latter  a  period  of  depression  alternates,  according  to  certain 
rules,  with  one  of  exaltation.  This  alternation  is  usually 
indicated  even  during  childhood,  and  the  patients  almost 
always  suffer  from  hereditary  taint  or  their  mental  condi- 
tion is  below  the  average  on  account  of  general  impair- 
ment of  the  entire  constitution.  The  completely  developed 
symptoms  are  generally  seen  only  in  asylums,  and  it  is 
then  found  that  the  periodical  course  is  due  to  causes  de- 
veloping within  the  body,  not  to  external  agencies.  Here, 
where  the  symptoms  are  not  changed  by  external  circum- 
stances, the  different  periods  are  found  to  resemble  one 
another  completely.  This  is  particularly  marked  at  the 
beginning  of  periodical  conditions  of  excitement.  These 
conditions  offer  an  unfavorable  prognosis,  inasmuch  as 
they  usually  persist  during  life.  A  long,  lucid  interval, 
or  a  prolonged,  only  slightly  depressed  period,  not  infre- 
quently simulates  recovery,  and  at  such  times  the  patient 
may  be  perfectly  responsible.  As  the  return  of  these  con- 
ditions is  due  to  internal  processes,  we  should  not  speak 
of  relapses,  but  should  reserve  this  term  for  those  forms 
of  insanity  in  which  the  new  disease  is  the  result  of  fresh 
external  causes.  The  psychoses  due  to  alcoholism  are 
illustrations  of  true  relapses. 

While  the  different  periodical  psychoses  may  vary 
greatly  in  duration,  yet  in  a  still  larger  number  of  cases 
their  duration  is  similar.  In  very  rare  cases  the  exact 
similarity  leads  to  the  suspicion  of  infectious  causes,  such 
as  malaria.  Indeed,  in  some  cases  a  previous  intermittent 
fever  impresses  its  periodicity  upon  subsequent  attacks, 
and  such  alternating  psychoses  exhibit,  for  a  time,  a  ter- 
tian or  quartan  type.  Their  subsequent  course,  however, 
does  not  exhibit  the  original  type. 

After  the  disease  has  developed  it  rarely  remains  at  the 
same  height.  This  is  true,  for  example,  of  the  not  frequent 
forms  of  so-called  constitutional  affective  insanity  which  oc- 


COURSE    OF   SYMPTOMS.  119 

cur  in  females  and  someti  mes  in  a  periodical  form .  In  peri- 
odical psychoses,  but  especially  in  simple  mental  disorders 
which  do  not  recover,  and  in  several  organic  psychoses, 
there  is  much  more  often  an  increase,  either  uniform  or 
by  fits  and  starts,  of  the  symptoms,  with  a  tendency  to 
mental  weakness.  In  a  certain  measure  it  is  true  that 
when,  after  a  primary  depressed  mood,  prolonged  excite- 
ment dominates  the  scene,  mental  weakness  will  finally 
develop  into  dementia. 

The  course  of  the  disease  is  rarely  effaced  by  the  fact 
that  it  becomes  complicated  with  other  forms  of  insanity. 
We  do  not  refer  to  the  varying  forms  of  the  periodical 
psychoses,  but  to  the  coincident  occurrence  of  several 
forms  of  disease,  such  as,  for  example,  melancholia  with 
a  former  congenital  weak-mindedness,  menstrual  insanity 
or  dementia  paralytica  with  paranoia,  alcoholic  insanity 
with  simple  psychical  disorders. 

Changes  for  the  better  or  worse  are  found  most  fre- 
quently during  the  subsidence  of  curable  psychoses. 
Convalescence  is  sometimes  accelerated  by  a.  severe  fever, 
such  as  typhoid  fever.  Otherwise,  as  a  rule,  the  signs  of 
emotional  excitement  are  first  lost;  and  evidences  of 
awakening  interest  in  the  outer  world  become  manifest. 
At  first  this  improvement  may  last  only  a  few  hours  or 
days,  and  bad  days  alternate  with  good  ones,  until  a  final 
advance  is  made  to  complete  recovery.  Even  after  the 
intellectual  disorder  has  entirely  disappeared,  the  emo- 
tional equilibrium  remains  unstable  for  a  long  time.  The 
former  healthy  personality  becomes  more  distinct ;  if  de- 
lusions or  hallucinations  make  their  appearance,  they  are 
recognized  as  such.  Facial  expression,  speech,  and  exter- 
nal appearance  remind  us  of  the  normal  condition,  sleep 
and  appetite  are  restored,  and  with  the  knowledge  of  the 
morbid  character  of  the  former  acts  the  transition  to  com- 
plete recovery  is  indicated. 

Certain  transitory  forms  of  insanity  last  only  a  few 
hours  or  days.  The  majority  of  simple  psychical  disor- 
ders which  recover  last  at  least  a  few  weeks,  and  gener- 


120  HANDBOOK   OF   INSANITY. 

ally  several  months.  When  the  causes  of  the  development 
of  the  disease  reside  within  the  patient's  own  body,  it  is 
more  apt  to  last  for  life.  A  duration  of  several  years  is 
not  very  rare  and  does  not  exclude  the  possibility  of 
recovery. 

Recovery  is  sometimes  attended  by  the  restoration  of 
certain  bodily  functions,  such  as  perspiration,  salivation, 
weeping,  menstruation,  which  had  been  checked  during 
the  disease.  In  rare  cases  a  favorable  influence  is  exerted 
by  local  inflammations,  such  as  abscesses,  boils,  parotitis, 
pneumonia,  infectious  diseases. 

Every  psychosis  which  does  not  improve,  passes  into  a 
chronic  stage.  The  impairment  of  the  mental  activities 
and  the  diminution  of  the  violent  symptoms  are  attended 
with  the  return  of  quiet  sleep,  good  digestion,  and  increas- 
ing weight  of  the  body.  The  patient  becomes  more  indif- 
ferent to  those  around  him.  This  condition  may  be  tem- 
porary and  may  tend  to  recovery  if  it  is  the  result  of 
mental  exhaustion.  But  if  the  return  of  the  former  psy- 
chical personality  does  not  go  hand  in  hand  with  the  bod- 
ily improvement,  then  recovery  is  improbable. 

The  term  incomplete  recovery  or  improvement  is  em- 
ployed when  the  remains  of  the  disease,  which  has  just  run 
its  course,  are  more  distinct  than  secondary  or  acquired  fee- 
ble-mindedness.  Such  patients  may  live  quietly  in  an 
asylum,  and  an  attempt  to  discharge  them  often  fails  be- 
cause the  unusual  requirements  in  the  life  of  the  outer 
world  rapidly  overthrow  their  equilibrium.  But  much 
depends  upon  circumstances.  If  his  home  is  a  happy  one, 
his  pecuniary  circumstances  good,  and  his  position  in 
life  assured,  the  patient  may,  perhaps,  return  home  and 
fill  his  place  in  a  tolerably  satisfactory  manner.  But 
even  in  the  apparently  mildest  forms  of  acquired  fee- 
ble-mindedness  we  always  notice  a  certain  weakness  of 
memory  and  impaired  mobility  of  the  emotions.  Un- 
cleanliness  in  person  and  dress  is  apparent ;  conduct  which 
is  devoid  of  tact,  irritability,  and  unbridled  yielding  to 
violent  affects  are  striking. 


MORTALITY.  121 

There  are  gradual  transitions  from  these  conditions  to 
complete  dementia.  The  patient  long  retains  the  memory 
of  past  times,  longest  of  the  mechanical  skill  which  he 
has  previously  acquired.  He  can  play  music,  work  at  his 
trade,  play  cards  or  even  chess;  later  everything  disap- 
pears. 

Simple  forms  of  insanity  do  not  prevent  long  life.  But, 
in  general,  the  mortality  of  the  insane  is  considerably 
higher  than  that  of  the  mentally  sound  population.  The 
insane  also  possess  a  greater  predisposition  to  certain 
bodily  diseases.  This  is  due  to  the  fact  that  the  mental 
disorder  gives  rise  to  irregularities  in  nutrition,  general 
anaemia,  lack  of  sensitiveness  to  injurious  external  influ- 
ences and  to  exposure  to  colds.  Overcrowding  of  asylums 
causes  further  injurious  factors,  especially  as  regards  epi- 
demics. The  frequency  of  tuberculosis  must  be  attributed 
to  living  in  crowded  apartments,  and  to  this  cause  the 
mortality  in  great  part  is  due.  Another  cause  is  the  diffi- 
culty of  early  recognition  of  intercurrent  diseases,  on 
account  of  the  disturbance  of  consciousness  and  the  fre- 
quent absence  of  manifestations  of  pain. 

Among  the  individual  causes  of  death,  the  mental  dis- 
ease itself  must  first  be  considered.  The  connection  is 
most  distinct  in  dementia  paralytica  and  its  underlying 
diffuse,  chronic  disease  of  the  cerebral  cortex.  The  pro- 
gressive paralysis  of  the  central  nervous  organs  proves 
fatal  by  the  paralytic  attacks,  decubitus,  severe  injuries, 
etc.  Feeble  heart's  action  and  imperfect  respiration  per- 
mit the  development  of  pneumonia,  as  in  paralytic  dements 
and  other  chronic  insane,  and  this  cause  of  death  is  about 
as  frequent  as  tuberculosis.  Anaemic  and  marantic  pa- 
tients are  most  apt  to  succumb  to  pneumonia  associated 
with  hypostasis.  In  such  cases  the  central  paralyses  of 
the  vasomotor  system  usually  lead  to  a  rapid  fatal  termi- 
nation. Demented  patients  suffer  from  chronic  intestinal 
catarrh,  due  to  the  ingestion  of  straw,  wood,  stones,  etc. , 
and  this  induces  rapid  loss  of  vital  energy.  Uncleanliness 
aids  the  development  of  furunculosis  after  slight  injuries, 


122  HANDBOOK   OF   INSANITY. 

and  this  is  followed  not  infrequently  by  erysipelas.  Fi- 
nally, numerous  surgical  affections  result  from  self-muti- 
lation or  injury  by  others,  and  may  be  the  cause  of  death 
on  account  of  the  impossibility  of  proper  treatment.  The 
brittleness  of  the  bones  is  a  predisposing  factor  in  many 
cases,  especially  in  dementia  paralytica.  There  is  marked 
disappearance  of  lime  salts,  especially  in  the  ribs.  Slight 
blows  cause  fracture  of  the  ribs,  and  not  infrequently  this 
gives  rise  to  pleurisy.  The  tendency  to  suicide  has  nu- 
merous victims,  especially  outside  of  asylums.  Obstinate 
refusal  to  take  food  is  generally  associated  with  gastric 
catarrh  and  may  terminate  in  death  after  extreme  exhaus- 
tion. 

B.    GENERAL   PROGNOSIS. 

The  prognosis  as  regards  life  often  depends  more  upon 
the  existence  of  other  bodily  diseases  than  on  the  condition 
of  the  brain  affection.  We  have  seen  that,  on  the  whole, 
insanity  diminishes  the  power  of  resistance  to  febrile  dis- 
eases. Further,  primary  nutritive  disorders  of  the  brain 
have  a  tendency  to  produce  permanent  tissue  changes  in 
the  brain  and  meninges.  Certain  forms  of  insanity  are 
characterized  by  immediate  inflammation  of  the  cortex. 
Of  these  the  most  dangerous  is  dementia  paralytica,  which 
proves  fatal  in  one  to  three  years,  often  in  a  shorter  period. 
An  unfavorable  prognosis  attaches  to  the  conditions  of 
excitement  which  are  due  to  severe  congestion  of  the 
brain.  The  cortex  may  soften  rapidly  in  some  layers  or 
a  hemorrhage  may  prove  rapidly  fatal.  Persistent  motor 
restlessness  and  insomnia  increase  the  danger  of  sudden 
collapse,  and  rapid  oedema  of  the  brain  may  also  develop 
under  such  circumstances.  The  more  violent  the  cause 
and  the  more  recent  the  disease,  the  greater  is  the  danger 
to  life ;  as  a  matter  of  course,  old  and  feeble  persons  suc- 
cumb most  readily.  Persistent  refusal  to  take  food  and 
attempts  at  suicide  are  most  frequent  in  recent  melancholic 
conditions.  Hence,  the  danger  of  a  fatal  termination  is 
much  greater  at  the  beginning  of  the  disease  in  a  recent 


PROGNOSIS.  123 

mania  or  melancholia.  After  the  affect  has  subsided 
and  mental  weakness  sets  in,  the  mortality  falls  consid- 
erably. 

The  prognosis  as  regards  recovery  from  insanity  requires 
much  greater  psychiatric  knowledge.  Milder  degrees  of 
mental  disorder  often  do  not  come  under  the  physician's 
notice,  and  run  a  favorable  course  in  the  family  circle. 
According  to  asylum  statistics  recent  cases  have  a  much 
more  favorable  prognosis  than  older  ones.  The  most  fre- 
quent recoveries  (up  to  sixty  per  cent)  are  obtained  in  the 
first  month  of  the  disease,  about  twenty  per  cent  in  the 
second  half  of  the  first  year,  and  at  the  most  twenty-five 
per  cent  in  the  second  year.  After  the  disease  has  lasted 
many  years,  recovery  occurs  in  very  rare  cases. 

Periodical  attacks  with  long  free  intervals  are  unfavora- 
ble as  regards  complete  recovery,  but  will  probably  improve 
very  materially.  At  first  these  patients  enter  the  asylums 
once  every  year,  every  three  years,  or  even  every  seven 
years,  but  in  time  the  attacks  become  more  prolonged  and 
the  free  intervals  shorter.  In  the  continued  cases  a  slow, 
gradual  development  usually  indicates  a  prolonged  course 
and  difficult  curability ;  a  sudden  outbreak  is  more  favor- 
able as  regards  recovery.  Sudden  recoveries  after  pro- 
longed duration  of  the  disease  are  suspicious,  and  slowly 
advancing  recoveries  are  usually  more  permanent.  Ir- 
regular changes  in  violent  symptoms  are  more  favorable 
than  long  persistence  in  the  same  course.  The  distinct 
advance  of  severe  symptoms  and  the  development  of  sys- 
tematized delusions  have  a  very  unfavorable  prognostic 
significance.  Especially  grave  in  this  respect  are  pro- 
tracted conditions  of  sexual  excitement,  which  end  usually 
in  dementia. 

It  is  a  favorable  sign  in  violent  mania  when  there  is 
not  alone  a  temporary  diminution  of  the  excitement,  but 
a  change  to  a  depressed  mood.  Such  changes  often  lead 
rapidly  to  the  normal  condition.  The  prognosis  is  favor- 
able in  all  cases  when,  with  beginning  quiet  and  clearness, 
the  former  likes  and  pleasures  make  their  appearance, 


124  HANDBOOK   OF   INSANITY. 

when  the  feeling  for  propriety  of  conduct  returns,  and  the 
love  for  the  family  is  restored. 

The  most  important  sign  of  real  recovery  is  the  decided 
recognition  of  the  disease  as  such  hy  the  patient.  Caution 
must  be  exercised,  however,  in  two  directions.  In  the 
first  place  there  is  a  possibility  of  intentional  deception, 
and  in  the  second  place  there  may  be  a  recognition  of  the 
morbid  character  of  the  mental  disorder  in  a  patient  al- 
though recovery  is  not  to  be  looked  for.  Hence,  the  value 
of  this  sign  in  prognosis  resides  in  the  fact  that  its  absence 
excludes  complete  recovery,  while  its  occurrence  after  the 
subsidence  of  violent  symptoms  usually  has  a  very  favor- 
able significance,  although  it  only  justifies  a  prediction  of 
probable  recovery.  In  ■  mental  weakness  this  symptom 
sometimes  develops  at  a  later  period.  As  a  rule,  it  is  dif- 
ficult for  the  convalescent  to  form  a  correct  judgment  con- 
cerning hallucinations,  especially  the  slight  impulse  to 
movement  which  attends  so  many  auditory  hallucina- 
tions. When  the  morbid  character  of  the  disease  has 
been  recognized,  the  patient  also  tolerates  mention  of 
the  occurrences  which  have  happened  during  his  illness. 
Whoever  carefully  avoids  such  memories  is  probably  not 
yet  normal,- but  has  merely  become  sufficiently  quiet  to 
conceal  his  delusions.  It  is  only  when  the  patient  recog- 
nizes the  pathological  changes  in  his  mental  life  as  some- 
thing strange,  that  he  is  able  to  express  thankfulness  for 
his  recovery. 

With  advancing  recovery,  sometimes  even  before  the 
mental  improvement,  bodily  improvement  also  takes  place. 
The  weight  increases,  appetite  and  sleep  improve.  An- 
other favorable  sign  is  the  return  of  former  ailments  which 
had  disappeared  during  the  insanity,  viz. ,  nervous  head- 
aches, digestive  disturbances,  etc.  But  if  complete  bodily 
health  develops  during  protracted  insanity,  the  prognosis 
is  very  unfavorable,  and  the  transition  into  imbecility  is 
probable.  Such  patients  may  become  extremely  obese. 
Slight  increase  of  weight,  however,  is  not  an  unfavorable 
sign. 


PROGNOSIS.  125 

There  is  a  difference,  as  regards  prognosis,  between 
hereditary  psychoses,  whose  outbreak  is  due  to  late 
accidental  causes,  and  those  in  which  heredity  has  pro- 
duced a  morbid  development  of  character  from  early 
childhood.  If  the  patient  with  hereditary  taint  has  been 
mentally  normal  until  his  attack  of  insanity,  the  prognosis 
of  the  single  attack  is  more  favorable  than  in  non-heredi- 
tary cases,  but  there  is  a  greater  predisposition  to  relapses. 

An  unfavorable  prognosis  usually  attaches  to  those  ac- 
quired forms  of  insanity  which  develop  after  injuries  to 
the  head,  insolation,  apoplexy,  meningitis,  and  particu- 
larly after  epilepsy. 

In  syphilitic  insanity  due  to  specific  changes  in  the 
brain,  great  success  is  sometimes  attained  temporarily  by 
inunction  treatment.  But  such  cases  are  exceptional, 
and  the  majority  terminate,  at  the  best,  in  feeble-minded- 
ness. 

When  general  anaemia,  menstrual  disorders,  curable 
diseases  of  the  genitalia,  and  mild  inflammations  of  the 
intestinal  canal  are  the  cause  of  insanity,  the  prognosis  is 
favorable.  This  is  also  true  of  insanity  after  febrile  dis- 
eases so  long  as  it  is  the  expression  of  ansemia  or  exhaus- 
tion of  the  brain,  while  complication  with  severe  diseases 
of  the  brain  or  with  a  serious  infection  or  intoxication 
makes  the  prognosis  poorer. 

The  prognosis  is  unfavorable  in  old  topers ;  here  the  in- 
sanity is  usually  attended  with  severe  inflammations  of 
the  meninges  and  even  the  cortex.  In  moderate  alcoholism 
many  cases  of  insanity  appear  to  have  a  favorable  prog- 
nosis, but  they  exhibit  an  unusual  tendency  to  relapses. 

Temporary  or  violently  acting  causes  permit  a  more 
favorable  prognosis  than  slowly  acting  causes  which  last 
for  years.  Thus,  in  continued  sexual  excitement  recovery 
is  rare,  while  masturbators  who  abandon  their  vice  may 
be  entirely  restored.  An  extremely  unfavorable  progno- 
sis obtains,  however,  in  those  cases  in  which  the  delu- 
sion of  a  close  union  with  the  supernatural  is  associated 
in  an  obscene  manner  with  the  tendency  to  masturbation. 


126  HANDBOOK   OF   INSANITY. 

Temporary  causes  which  act  only  once,  such  as  pregnancy, 
the  puerperal  condition,  and  nursing,  allow  a  very  favor- 
able prognosis. 

It  is  on  account  of  this  latter  group  of  cases  that  the 
prognosis  as  regards  curability  in  general  is  better  in  fe- 
males, while  drunkenness  and  the  injurious  influences 
attending  the  struggle  for  life  still  further  aggravate  the 
prognosis  in  males. 

The  significance  of  age  in  prognosis  is  easily  understood. 
Childhood  is  greatly  endangered  by  the  so  frequent  hered- 
itary taint ;  in  youth  the  prognosis  of  insanity  is  much 
more  favorable  than  in  advanced  age.  Puberty  and  the 
climacteric  furnish  a  favorable  prognosis  only  when  there 
is  no  hereditary  taint. 

We  will  now  consider  the  prognosis  of  a  few  individual 
symptoms.  A  profound  disturbance  of  consciousness,  de- 
veloping gradually  in  the  course  of  the  disease,  indicates 
an  unfavorable  termination,  while  its  sudden  occurrence  is 
more  favorable.  The  impulse  to  collect  articles,  loss  of  the 
sense  of  modesty,  and  uncleanliness  during  violent  mania, 
are  not  so  grave  as  in  chronic  conditions  with  extinguished 
affects.  Incoherency  and  firm  delusions  during  excite- 
ment may  disappear ;  without  excitement  they  are  usually 
signs  of  mental  weakness.  Permanent  impairment  of 
memory  has  an  evil  significance.  If  confusion  is  accom- 
panied by  new-formed  words  the  prognosis  is  bad. 

Insensibility  to  heat  and  cold,  staring  into  the  bright 
sunlight,  absence  of  the  feeling  of  satiety,  the  ingestion 
of  nauseous  articles,  especially  of  excrement,  are  found 
almost  exclusively  in  severe,  unfavorable  cases.  Condi- 
tions of  sexual  excitement  before  and  after  the  period  of 
potency  are  of  grave  omen,  especially  the  rekindling  of 
sexual  desire  in  old  men. 

Visual  hallucinations  usually  occur  only  in  recent  cases, 
auditory  hallucinations  in  chronic  ones,  and  the  latter, 
like  olfactory  hallucinations,  are  grave  signs.  Still  more 
unfavorable  is  the  combination  of  hallucinations  in  several 
sensory  tracts. 


MOTOR   SYMPTOMS   IN   PROGNOSIS.  127 

Actions  which  are  done  apparently  without  motive  and 
which  are  subsequently  defended  with  various  reasons 
have  a  very  bad  significance.  Like  crankiness,  they  point 
to  degeneration-insanity.  Imperative  concepts,  move- 
ments, and  impulsive  imperative  acts  are  also  symptoms 
of  the  same  morbid  group;  or  they  indicate  profound 
organic  destruction  of  the  tissues,  as  in  the  rhythmical 
and  stereotyped  imperative  movements  of  imbeciles. 

Among  the  purely  bodily  disturbances  the  motor  symp- 
toms are  most  important  as  regards  prognosis.  Par- 
alyses, spasms,  and  disorders  of  co-ordination  as  attend- 
ants of  psychoses  are  usually  due  to  severe  diseases  of 
the  central  nervous  system,  unless  they  are  hysterical  in 
character.  Catalepsy  associated  with  disturbance  of  con- 
sciousness also  occurs  in  curable  cases,  and  muscular  tre- 
mor is  not  always  an  unfavorable  sign;  for  example, 
in  the  beginning  of  alcoholism,  anaemia,  and  nervous  ex- 
citement; but  if  associated  with  paralyses  of  the  limbs 
or  ocular  muscles  it  is  more  serious.  Difference  in  the 
size  of  the  pupils  and  strabismus,  if  not  habitual,  can 
only  be  utilized  in  association  with  other  symptoms. 
Rigidity  and  contraction  of  the  pupils  rouse  the  suspicion 
of  progressive  paresis.  Disturbances  of  speech,  so-called 
syllabic  stuttering,  and  the  corresponding  disorders  of 
writing  point  to  the  same  unfavorable  form  of  disease, 
but  may  also  occur  in  general  neurasthenia.  Continued 
gritting  of  the  teeth  is  an  indication  of  severe  irritation 
of  the  cerebral  cortex.  Continued  flow  of  saliva  hardly 
ever  occurs  except  in  higher  grades  of  mental  weakness ; 
at  the  same  time  there  are  usually  pronounced  changes  of 
mimic  innervation.  An  unfavorable  termination  is  often 
revealed  at  an  early  period  by  the  staring,  expressionless 
gaze,  and  the  distortion  of  the  features  due  to  unequal 
innervation.  If  the  features  and  posture  are  relaxed,  the 
chin  depressed,  the  saliva  flowing  from  the  angles  of  the 
mouth,  and  the  faeces  and  urine  are  passed  involuntarily, 
then  the  transition  into  imbecility  has  generally  taken 
place.     On  the  other  hand,  recovery  is  early  manifested 


128  HANDBOOK   OF   INSANITY. 

when  the  features  clear  up,  and  the  normal  play  of  features 
of  the  former  personality  again  develops. 

Neuralgias  have  no  significance  in  prognosis,  while 
anaesthesia  and  analgesia  are  decidedly  unfavorable.  The 
severe  trophic  disorders,  such  as  othematoma  and  fragility 
of  the  ribs,  almost  always  indicate  a  termination  in  death 
or  dementia. 

The  absence  of  the  menses  in  recent  cases  is  not  unusual, 
but  their  return  is  always  a  desirable  sign.  If  menstrua- 
tion returns  before  improvement  of  the  mental  condition, 
it  indicates  at  least  an  improvement  in  the  vegetative  con- 
ditions of  the  organism,  and  is  occasionally  the  precursor 
of  recovery ;  but  if  improvement  does  not  occur  soon,  then 
the  return  of  menstruation,  like  that  of  other  bodily  func- 
tions, without  mental  improvement,  has  an  unfavorable 
prognostic  significance, 


THE  DIAGNOSIS  OF   MENTAL  DISORDERS  AND  THEIR 
BORDER   LINES. 

A.    GENERAL   STANDPOINT. 

A  psychiatric  diagnosis  is  in  the  main  a  psychological 
one.  But  although  the  psychoses  are  diseases  which  run 
their  course  particularly  in  the  psychical  domain,  yet  the 
accompanying  bodily  symptoms  may  not  be  neglected. 
Definite  diagnoses  are  based  less  upon  single,  undeniable 
manifestations  of  disease  than  upon  definite  groups  of 
phenomena.  Everything  depends  upon  the  interpretation 
of  the  mental  acts  by  the  observer.  For  example,  in  the 
uneducated  a  belief  in  witches  cannot  at  once  be  regarded 
as  an  evidence  of  disease,  while  such  a  belief  in  a  cultured 
individual  forces  us  to  investigate  the  reasons  which  have 
led  him  to  this  belief. 

More  or  less  difficulties  in  diagnosis  are  created  by  the 
families  of  the  patients,  who,  to  a  greater  or  less  extent, 
acquire  the  habit  of  accepting  his  delusions  as  real.  They 
attribute  the  disease  to  entirely  immaterial  causes ;  they 
weaken  the  significance  of  the  patient's  wrong  acts  or  jus- 
tify them.  If  the  patient  has  attacked  a  passer-by,  they 
explain  that  the  former  must  have  been  irritated.  On  the 
other  hand,  the  patient  himself  offers  serious  difficulties. 
Usually  there  is  distrust  of  the  physician,  because  the  pa- 
tient's feeling  of  uncertainty  concerning  his  own  mental 
functions  makes  him  fear  removal  to  an  asylum.  Hence, 
he  refuses  to  proclaim  his  delusions,  and  is  either  silent 
or  gives  unsatisfactory  answers.  It  is  only  in  exceptional 
cases  that  patients,  with  a  certain  consciousness  of  their 
own  illness,  voluntarily  lay  bare  their  internal  condition 
to  the  physician. 

9  129 


130  HANDBOOK    OF   INSANITY. 

The  existence  of  a  psychosis  may  not  be  denied  on  ac- 
count of  the  incomplete  resemblance  of  the  case  to  one 
of  the  principal  forms  of  insanity,  because  there  are  various 
mixed  forms  or  incompletely  developed  varieties  of  insan- 
ity. As  a  rule,  it  is  not  difficult  to  discover  at  least  the 
general  signs  of  excitement,  depression,  or  mental  weak- 
ness, although  even  this  is  not  always  patent.  In  such 
cases  the  patient's  acts  furnish  better  information. 

The  chief  evidence  of  the  existence  of  a  psychosis  is  a 
change  in  the  character  of  the  psychical  life,  in  the  pa- 
tient's moods,  feelings,  tendencies,  habits,  volitions,  and 
judgments.  Hence,  his  previous  character  must  be  known 
to  the  physician  or  must  be  described  to  him  by  others. 
In  some  cases,  however,  there  is  merely  a  higher  develop- 
ment or  intensification  of  the  prominent  characteristics. 
The  change  is  also  indistinct  in  congenital  conditions. 

The  diagnosis  of  mental  disturbance  in  children  presents 
special  peculiarities.  For  example,  it  is  not  always  easy 
to  determine,  at  an  early  period,  slight  degrees  of  feeble- 
mindedness. A  late  acquisition  of  speech  is  usually 
noticed  even  by  the  parents,  also  the  rapidity  with  which 
study  tires  the  child.  It  is  especially  important  to  dis- 
tinguish congenital  or  early  deaf -mutism  from  imbecility. 
In  the  latter  condition  the  child  is  dull  and  apathetic,  and 
looks  aimlessly  about  him;  in  the  former,  he  looks  with 
an  attentive  expression  upon  the  speaker.  Tests  of  hear- 
ing then  give  further  information. 

A  complete  diagnosis  includes  a  knowledge  of  the  cau- 
sation of  the  disease.  The  patient's  previous  life  must  be 
investigated  in  all  directions  in  order  to  understand  the 
development  and  course  of  the  disease.  In  this  way  we 
will  avoid  the  error  of  making  a  diagnosis  of  a  definite 
form  of  disease  from  a  single  symptom,  inasmuch  as  there 
are  no  so-called  pathognomonic  symptoms. 


EXPRESSION   OF   MOODS.  131 

B.    PSYCHIATRIC  EXAMINATION. 

1.  Diagnosis  of  the  Disease. 

The  examination  is  begun  in  a  somewhat  similar  man- 
ner to  that  employed  in  any  other  disease.  The  name, 
age,  and  occupation  are  first  obtained.  This  will  deter- 
mine, in  a  rough  way,  whether  consciousness  is  impaired 
or  unclouded,  whether  memory  is  retained,  or  the  course 
of  ideas  is  accelerated  or  retarded.  The  bodily  posture, 
gestures,  and  facial  expression  will  then  furnish  sufficient 
data  to  enable  us  to  continue  the  examination  in  certain 
directions.  In  excited  patients  the  further  course  of  the 
examination  will  be  guided  by  the  manifestations  of  dis- 
ease themselves,  in  self-contained  individuals  we  reach 
further  facts  and  observations  by  questions  concerning  the 
events  of  their  former  life,  while  completely  irrational  pa- 
tients soon  compel  us  to  regard  the  present  condition,  which 
is  then  made  clearer  by  the  statements  of  the  family.  As 
a  general  thing,  however,  we  should  allow  the  impres- 
sion made  by  the  patient  to  act  upon  us  in  as  unbiassed  a 
manner  as  possible,  and  to  gain  his  confidence  by  dilating 
quietly  upon  his  present  notions.  Excessive  questioning, 
at  the  start,  is  apt  to  intimidate  the  patient  or  to  produce 
distrust.  Gradually  we  may  enlarge  upon  the  symptoms 
which  are  exhibited  voluntarily. 

Among  these  the  expression  of  the  mood  is  almost  al- 
ways the  first.  In  recent  cases,  as  a  rule,  affects  appear 
very  clearly.  The  cheerful  mood  is  disclosed  freely,  and 
there  is  no  objection  in  calling  the  patient's  attention  at 
once  to  the  fact  that  there  is  no  reason  for  mirth  in  his 
present  position.  He  will  either  pay  no  attention  to  this 
reprimand  or  he  is  not  infrequently  led  to  disclose,  in  rapid 
speech,  his  inner  feelings.  In  this  event  we  attempt  to 
ascertain  disorders  in  the  course  of  his  ideas,  which  are 
rapidly  shown  in  the  higher  grades  of  cheerful  excitement, 
but  require  careful  observation  in  the  slighter  grades.  A 
certain  degree  of  loquacity  and  jumping  from  one  subject 
of  conversation  to  another  are  important  signs  in  the  diag- 


132  HANDBOOK   OF   INSANITY. 

nosis  of  a  condition  of  excitement.  Great  aid  is  furnished 
by  observing  the  movements  of  expression.  While  cheer- 
ful excitement  presents  a  frequent  change  of  expression, 
in  depressed  moods  our  attention  can  be  directed  for  a 
longer  time  to  their  external  signs.  The  melancholic  thus 
furnishes  an  excuse  for  asking  him  concerning  the  reason 
of  his  depression,  but  if  his  despair  is  known  to  be  un- 
founded we  should  avoid  calling  his  attention  thereto  in 
order  that  distrust  may  not  be  aroused.  A  friendly,  sym- 
pathetic manner  is  necessary  if  we  wish  to  ascertain 
whether  the  melancholic  affect  results  from  delusions  and 
hallucinations,  or  whether  there  is  a  simple  affective  con- 
dition. To  the  existence  of  these  two  conditions,  viz., 
delusions  and  hallucinations,  the  examination  must  now 
be  directed  unless  the  patient  himself  has  already  revealed 
them. 

Delusions  are  very  characteristic  of  certain  psychoses. 
In  the  beginning  of  the  disease  the  patient,  in  many  cases, 
instinctively  attempts  to  conceal  them,  and  eludes  all  at- 
tempts to  discover  them  until  some  point  is  touched  which 
throws  him  into  an  affect,  or  until,  by  means  of  all  sorts 
of  questions,  a  point  of  contact  is  found  through  which 
the  entire  chain  of  morbid  ideas  may  be  developed,  appa- 
rently without  intention.  The  conduct  of  the  patient  some- 
times puts  us  on  the  trail.  A  distrustful  bearing  rouses 
the  suspicion  of  the  notion  of  secret  enemies  and  persecu- 
tions. Excessive  self-satisfaction,  which  is  often  exhibited 
in  the  dress,  indicates  ideas  of  grandeur,  while  frequent 
prayers  and  tearful  expression  make  it  probable  that  we 
have  to  deal  with  the  delusion  of  having  committed  a 
crime,  with  a  religious  color.  Not  every  statement  of  a 
peculiar  character  must  be  regarded  as  a  delusion,  because 
the  insane,  like  the  sane,  may  be  mistaken,  or  the  idea 
of  jealousy,  for  example,  may  be  based  on  fact.  Thus,  so 
far  as  regards  its  contents,  the  delusion  of  jealousy  of  the 
alcoholic  cannot  be  distinguished  from  a  possible  mistake. 
But  more  frequently  the  delusions  are  so  peculiar  that  their 
morbid  character  strikes  us  at  once. 


CONTENTS   OF   DELUSIONS.  133 

The  contents  of  delusions  may  be  built  up  from  the  en- 
tire experience  of  man,  yet  the  main  elements  of  delusions 
exhibit  such  a  widespread  agreement  with  one  another 
that  the  experienced  observer,  relying  upon  inferences 
drawn  from  external  appearances,  is  often  able,  with  sur- 
prising rapidity,  to  obtain  from  the  astonished  patient  the 
confession  of  his  morbid  ideas.  It  is  a  notable  fact  that 
the  same  morbid  ideas  appear  in  so  many  patients.  In 
the  individual  cases  the  principal  groups  of  delusions 
(which  have  already  been  discussed)  are  easily  recognized 
as  variations  of  the  same  theme,  and  the  diagnosis  will 
quickly  distinguish  depressive  notions  of  self-impairment 
or  expansive  ideas  of  grandeur.  There  is  no  material  dif- 
ference, so  far  as  regards  the  medical  diagnosis,  whether 
a  mother  says  that  she  or  her  children  are  poisoned.  If 
a  patient  revels  in  ideas  of  great  wealth  it  is  immaterial, 
so  far  as  regards  our  interpretation  of  his  statements  as 
delusions,  whether  the  treasures  consist  of  mountains  of 
gold  or  more  modest  sums.  These  differences  possess 
value  in  diagnosis  only  in  so  far  as  they  are  evidences  of 
absence  of  judgment  and  thus  become  a  measure  of  the 
degree  of  mental  weakness  which  in  a  greater  or  less 
degree  accompanies  all  delusions. 

In  a  series  of  cases  depressive  and  expansive  delusions 
are  both  present.  They  may  appear  in  rapid  alternation, 
but  even  then  one  group  is  the  more  prominent.  A  mani- 
acal patient  may  say,  in  the  same  breath:  I  have  been 
poisoned,  I  am  the  king;  a  paralytic  dement,  with  the 
most  florid  delusions  of  grandeur,  may  say  that  he  will  be 
killed  to-day;  or  a  profoundly  melancholic  patient  may 
casually  remark  that  he  lives  in  a  palace,  surrounded 
by  princes.  Such  brief  expressions  of  opposite  moods  are 
not  rare  in  recent  affective  conditions,  and  do  not  compel 
the  diagnosis  of  an  unfavorable  form  of  disease.  But  if 
the  two  principal  groups  of  delusions  develop  slowly 
alongside  of  one  another,  so  that,  for  example,  the  antag- 
onistic notions  of  delusions  of  grandeur  and  of  persecution 
have  had  time,  during  a  number  of  years,  to  form  firm 


134  HANDBOOK    OF   INSANITY. 

combinations  and  to  grow  "together  into  a  firm  system, 
then  we  have  to  deal  with  a  more  serious  ailment,  with 
"  verruecktheit  "  in  the  proper  sense  of  the  word. 

We  must  next  ascertain  whether  the  delusions  are  ac- 
companied by  hallucinations,  and  which  have  developed 
first  in  point  of  time.  As  the  latter  do  not  develop  on  the 
same  basis,  in  so  far  as  they  are  peripheral  in  origin, 
this  must  first  be  examined,  because  certain  peripheral 
hallucinations  are  susceptible  of  direct  treatment.  If  the 
hallucinations  have  developed  centrally  in  the  cortex,  it 
will  probably  be  impossible  to  determine  the  period  of 
their  development.  Their  relationship  and  similarity  of 
development  are  then  so  great  that  in  many  cases  halluci- 
nations may  only  be  regarded  as  delusions  which  are  pro- 
vided with  a  vivid  sensory  accompaniment.  In  this  respect 
we  may  refer  to  all  those  relations  which  may  be  recognized 
between  auditory  hallucinations  and  their  expression  in 
speech.  The  firm  association  between  concept  and  lan- 
guage makes  it  easy  for  us  to  understand  the  powerful  con- 
vincing power  of  auditory  hallucinations  which  readily 
overcomes  the  critical  objections  of  reason.  It  must  be 
borne  in  mind  that  the  basis  is  cerebral  and  not  merely 
logical.  Hence  delusions,  like  hallucinations,  may  also 
appear  in  antagonism  to  the  predominant  moods  and  feel- 
ings. 

As  a  regular  connection  between  certain  sensations  (as- 
sociated sensations)  takes  place  along  definite  nerve  tracts, 
in  like  manner  we  must  assume  the  development  of  certain 
delusions  and  hallucinations  as  connected  with  definite 
tracts,  so  that  they  must  always  develop  in  the  same 
manner  after  certain  peripheral  or  cerebral  stimuli  (asso- 
ciated concepts) .  In  this  way  alone  can  we  explain,  in  a 
measure,  the  narrow  range  and  repetition  of  the  contents 
of  primordial  delirium,  which  are  found  on  the  whole  to 
be  independent  of  the  mood  and  of  the  special  form  of  dis- 
ease. 

The  search  for  hallucinations  is  often  facilitated  by  the 
patient's  manner.      A  listening  attitude,  staring  at  one 


HISTORY   OF   THE   PATIENT.  135 

point,  sudden  starting  and  speaking  are  occasionally  very 
characteristic.  The  diagnosis  is  easier  when  the  patient 
speaks  of  "voices"  and  "images."  The  simple  mention 
of  electrical  or  magnetic  influences,  etc.,  if  made  casually, 
sometimes  induces  the  individual  to  express  his  secret 
thoughts. 

Peculiarities  in  the  surroundings,  for  example,  in  the 
furniture  of  the  room,  may  also  guide  the  diagnosis. 
After  a  few  questions  to  test  the  memory,  we  must  en- 
deavor to  obtain  from  the  patient  (or  those  around  him)  a 
history  of  his  previous  condition.  It  is  of  great  practical 
importance  to  question  the  patient  and  his  family  sepa- 
rately. We  must  particularly  avoid  unreserved  accept- 
ance of  the  statements  of  the  family,  especially  as  they 
are  inclined  to  regard  signs  of  the  already  existing  disease 
(for  example,  excesses  of  all  kinds)  as  causes  of  the  men- 
tal disorder. 

The  hereditary  conditions  must  first  be  ascertained — 
the  existence  of  insanity  in  the  relatives,  the  special  form 
of  the  disease,  the  occurrence  of  nervous  diseases  of  all 
kinds,  of  drunkennesss,  or  a  tendency  to  suicide.  Under 
certain  circumstances  we  must  inquire  into  the  question 
of  hereditary  syphilis  or  tuberculosis,  or  whether  concep- 
tion took  place  during  drunkenness  or  the  epileptic  condi- 
tion. 

We  proceed  next  to  the  history  of  the  development  and 
growth  of  the  patient — whether  injurious  influences  were 
at  work  during  pregnancy  or  parturition,  whether  the  de- 
velopment of  the  brain  was  impaired  by  diseases  of 
infancy;  whether  convulsions  appeared  at  a  later  period. 
We  then  enter  upon  the  peculiarities  of  the  further  bodily 
development,  especially  sexual  development  and  mastur- 
bation, the  timely  or  premature  occurrence  of  puberty  and 
menstruation.  The  questions  next  extend  to  the  time  at 
which  the  patient  learned  to  speak,  the  progress  in  school, 
social  tendencies,  and  the  peculiarities  of  character.  With 
regard  to  later  life  we  must  ascertain  the  occurrence  of 
exhausting  diseases  which  lead  to  anaemia. 


136  HANDBOOK   OF   INSANITY. 

The  investigation  then  passes  to  the  patient's  occupa- 
tion, his  marital  and  social  relations,  etc. 

Special  importance  attaches  to  the  disappearance  of 
ethical  feelings,  of  love  for  the  family,  defective  sense  of 
propriety,  the  aesthetic  feelings  in  general. 

We  must  also  ascertain  whether  the  disease  began  sud- 
denly or  slowly,  whether  disturbances  of  consciousness 
occurred  at  the  onset  or  later,  whether  the  disorder  was 
continuous  or  progressed  by  fits  and  starts.  The  previous 
history  often  justifies  renewed  examination  of  the  present 
mental  condition  and  this  may  facilitate  the  correct  diag- 
nosis. 

Physical  examination  of  the  body  must  now  be  under- 
taken. The  most  important  point  is  the  character  of  the 
sleep,  then  the  general  nutrition,  adipose  development, 
muscular  strength,  and  weight  of  the  body. 

Examination  of  the  bodily  temperature  often  requires 
special  care,  because  the  other  diagnostic  aids  in  the  rec- 
ognition of  bodily  diseases  are  often  wanting  in  the  insane. 

The  vasomotor  system  is  almost  always  implicated. 
This  is  shown  most  distinctly  in  paralyses  of  large  vascu- 
lar tracts  or  in  more  or  less  circumscribed  tracts,  the  walls 
of  whose  vessels  offer  a  diminished  resistance  to  the  cur- 
rent of  blood.  The  experienced  touch  easily  recognizes 
the  pulsus  tardus  of  many  insane. 

Physical  examination  of  the  lungs  must  not  be  neglected, 
because  pulmonary  diseases  in  the  insane  occasionally  run 
their  course  without  a  rise  of  temperature. 

As  a  matter  of  course,  the  condition  of  the  digestive 
organs  merits  special  consideration.  In  recent  cases  of 
melancholia  gastric  catarrh  is  sometimes  the  exciting 
cause  of  concepts  from  which  the  refusal  to  take  food 
develops. 

As  regards  gynecological  examinations,  it  is  better  to 
do  too  little  than  too  much,  and  they  should  be  made  only 
when  there  is  a  definite  indication.  It  is  advisable  to 
make  such  examinations  only  in  the  presence  of  witnesses. 

Examination  of  the  urine  is  desirable,  and,  whenever 


EXAMINATION   OF   EYEWEAR,    AND    SKIN.  137 

there  is  marked  emaciation,  the  tests  for  sugar  should  be 
applied. 

Ophthalmoscopic  examination  is  necessary,  because  con- 
gestion of  the  brain  and  the  fundus  often  go  hand  in 
hand.  Retinal  diseases,  especially  retinitis  pigmentosa, 
and  opacities  of  the  refracting  media  may  help  to  explain 
visual  hallucinations. 

Examination  of  the  ear  is  equally  important.  The  re- 
moval of  hardened  wax  has  often  relieved  auditory  hallu- 
cinations. Plugging  the  ear  with  cotton  sometimes  leads 
to  the  suspicion  of  auditory  hallucinations  which  were, 
perhaps,  not  apparent  from  the  manner  and  conversation 
of  the  patient.  Inflammations  of  the  middle  ear  some- 
times lead  to  the  recognition  of  purulent  meningitis  and 
thrombosis  of  the  sinuses,  whose  occasional  connection 
with  psychoses  has  been  observed. 

When  olfactory  hallucinations  are  present  the  nose 
should  be  examined. 

The  tests  for  cutaneous  sensibility  must  be  accepted 
with  great  reserve.  The  examination  of  motility  is  very 
important  because  motor  disorders,  when  associated  with 
insanity,  are  usually  the  expression  of  severe  diseases  of 
the  brain.  The  combination  of  psychoses  with  focal  dis- 
eases of  the  brain  and  external  injuries  may  also  give  rise 
to  numerous  motor  symptoms.  The  significance  of  such 
symptoms  should  not  be  overestimated  in  severe  cases  of 
alcoholism.  The  further  course  and  the  previous  history 
will  generally  prevent  a  mistake  with  the  usually  more 
persistent  but  similar  disorders  of  paralytic  dementia.  On 
the  other  hand,  the  changeableness  of  some  paralyses  does 
not  exclude  severe  cerebral  disease.  In  dementia  para- 
lytica, for  example,  the  paralyses  sometimes  change  their 
locality  or  disappear  for  a  time  in  a  few  hours  or  days ; 
differences  in  the  size  of  the  pupils  may  pass  from  one 
side  to  the  other.  Phenomena  of  this  kind  are  also  ob- 
served in  some  other  forms  of  insanity.  Mistakes  are, 
only  avoided  by  taking  into  consideration  all  the  other 
symptoms  of  the  case.     It  may  here  be  mentioned  that 


138 


HANDBOOK   OF   INSANITY. 


very  wide  pupils,  with  good  reaction  to  light  and  accom- 
modation, are  found  often  in  hysteria  and  mania,  while 
this  symptom  is  wanting  in  epileptic  attacks,  meningitis, 
and  increased  cerebral  pressure  in  general.  The  mobility 
of  contracted  pupils  is  ascertained  with  difficulty,  but 
pronounced  narrowing  is  an  important  sign  of  profound 
disease  of  the  brain,  and  is  very  frequent  in  beginning 
dementia  paralytica. 

Great  scientific  interest  attaches  to  the  examination  of 
the  skull,  although,  in  the  diagnosis  of  psychoses,  only 
the  most  marked  changes  come  into  question.  These 
never  occur  when  the  mental  condition  is  entirely  normal, 
while  variations  from  the  normal  are  also  found  in  the  skulls 
of  sane  individuals.  These  include  the  sexual  differences. 
The  female  skull  is  smaller,  on  the  whole ;  its  height  is 


Fig.  8.— (After  Merkel.) 


less,  but  its  breadth  is  more  developed.  The  base  of  the 
female  skull  is  narrower  and  shorter.  The  most  strik- 
ing peculiarity  of  the  female  skull,  as  seen  in  the  living 
subject  in  profile,  is  the  line  of  the  upper  curvature ;  the 


VARIATIONS   IN   THE   SKULL.  139 

flattening  of  the  parietal  region  passes  quite  suddenly  on 
the  one  side  into  the  vertical  frontal  line,  on  the  other  side 
into  the  sloping  line  of  the  occiput,  so  that  more  or  less  an- 
gular curves  develop  on  both  sides.     In  the  male  skull 


Fig.  9.— (After  Merkel.) 

this  line  is  arched ;  seen  from  the  front,  it  is  also  distin- 
guished by  the  greater  prominence  of  the  parietal  emi- 
nences, so  that  it  becomes  angular  compared  with  the 
rounded  female  skull. 

In  the  different  races  we  find  numerous  variations  in 
the  skull,  which  cannot  be  utilized  in  the  diagnosis  of 
psychoses  because  they  are  often  observed  in  the  sane; 
for  example,  large  uniformly  developed  skulls,  kephalones. 
On  the  other  hand  small  skulls,  microcephalus,  generally  re- 
veal an  abnormal  formation  of  the  brain.  Among  other 
forms  I  will  call  attention  to  the  very  frequent  saddle  head 
(Fig.  10),  in  which  a  saddle-shaped  depression  occupies  the 
site  of  the  large  fontanelle. 

The  foetal  brain  does  not  fill  the  skull   completely,   a 


140  HANDBOOK    OF    INSANITY. 

considerable  space  between  the  two  being  filled  with 
fluid.  In  its  further  growth  the  brain  changes  its  posi- 
tion in  relation  to  the  skull  because  the  hemispheres 
grow  mainly  from  in  front  backward.  The  brain  pro- 
bably continues  to  grow  until  the  age  of  twenty-five 
years,  but  the  growth  of  the  skull  ceases  much  earlier. 
From  birth  until  the  seventh  year  the  skull  grows  rapidly, 
then  there  is  almost  complete  standstill  until  puberty,  and 
during  this,  latter  period  it  is  supposed  that  the  brain  grows 


Fig.  10. — (After  Merkel). 

more  markedly.     After  puberty  the  skull  grows  in  a  more 
uniform  manner. 

Three  factors  come  into  play  in  the  growth  of  the  skull — 
the  growth  of  the  brain,  constituting  a  force  which  presses 
from  within  outward;  the  traction  or  pressure  of  the 
muscles  attached  to  the  skull;  and  the  structure  of  the 
bones  themselves.  These  influences  are  more  important 
than  pelvic  pressure  during  birth.  The  effects  of  the 
latter  may  last  for  months  and  years,  but  the  brain  is 
immature  and  there  is  conriderable  room  for  accommoda- 
tion within  the  skull.  The  three  factors  mentioned  must 
always  be  considered  as  coincident  in  point  of  time.  That 
the  shape  of  the  skull  is  influenced  by  the  growth  of  the 
brain  is  shown  by  the  unilateral  flattening  in  idiots  with 
atrophy  of  one  hemisphere.     Slight  differences  between  the 


GROWTH    OP   THE   SKULL.  141 

two  halves  of  the  skull  possess  little  value  in  psychiatric 
diagnosis. 

Among  the  muscular  forces  the  chief  part  is  played  by 
the  traction  of  the  muscles  of  the  neck  and  the  pressure  of 
the  muscles  of  mastication.  Strongly  developed  muscles 
on  the  back  of  the  neck  flatten  the  occipital  curve,  while 
feeble  muscles  increase  its  convexity;  if  the  bones  are 
soft,  as  in  rickets,  a  permanent  deformity  may  result. 
Vigorous  temporal  muscles  narrow  the  skull.  In  an  oc- 
cupation which  leads  to  permanent  obliquity  of  the  trunk 
(and  therefore  of  the  head)  the  muscles  of  the  neck  act 
unilaterally  and  the  skull  becomes  oblique.  As  a  matter 
of  course,  such  a  scoliotic  skull  is  not  a  sign  of  mental 
disturbance. 

The  growth  of  the  bones  may  be  changed  in  general 
rachitis,  and  constant  lying  on  the  occiput  may  be  injuri- 
ous in  rachitic  children.  Another  significance  attaches 
to  ossification  of  the  sutures.  As  a  general  thing,  the  de- 
velopment of  the  skull  is  retarded  in  a  direction  perpen- 
dicular to  the  ossifying  suture.  If  the  ossification  occurs 
prematurely,  it  leads  to  extremely  pronounced  changes, 
especially  at  the  base  of  the  skull. 

Meningitides  in  early  life  may  change  the  intracranial 
pressure  and,  in  combination  with  other  causes  acting 
from  the  outside,  may  lead  to  various  deformities  of  the 
skull. 

In  making  measurements  we  follow  the  plan  adopted 
by  the  German  Anthropological  Society. 

The  horizontal  plane  (Fig.  11,  h  h)  is  determined,  on  the 
macerated  skull,  by  two  straight  lines  which  connect,  on 
both  sides,  the  lowest  point  of  the  inferior  rim  of  the  orbit 
with  a  point  in  the  upper  rim  of  the  auditory  canal  lying 
vertically  above  the  middle  of  the  auditory  meatus.  In 
the  living  subject  this  plane  can  only  be  determined  ap- 
proximately, but  with  sufficient  accuracy  for  practical 
purposes.  The  plane  can  be  rendered  visible  by  applying 
a  rubber  ring.  The  head  to  be  examined  must  be  placed 
in  such  a  position  that  this  plane  is  parallel  to  the  natural 


142 


HANDBOOK    OF    INSANITY. 


horizon.  The  horizontal  planes  should  be  marked  out 
before  taking  the  longitudinal  dimensions  of  the  skull, 
because,  when  the  occiput  is  very  prominent,  the  greatest 
length,  Lgr  (to  the  external  occipital  protuberance)  does 
not  coincide  with  the  ordinary  measure  of  length,  the  so- 
called  straight  length  L  which  passes  from  the  middle  of 
the  arch  of  the  eyebrows  above  the  nose  to  the  most 
prominent  point  on  the  occiput,  parallel  to  the  horizontal 
plane.  The  auricular  or  ear  height,  OH,  is  the  distance 
between  the  upper  rim  of  the  auditory  meatus  to  the  point 


Fig.  11. 


of  the  vertex  situated  above  it  in  a  vertical  line.  The 
greatest  width  is  measured,  wherever  it  may  be  found,  to 
the  exclusion  of  the  mastoid  processes.  The  distances  be- 
tween the  malar  processes  and  between  the  auditory 
foramina  are  measured  with  a  pair  of  compasses,  the 
other  distances  are  measured  with  the  tape. 

A  certain  proportion  of  breadth  to  length  has  given  rise 
to  the  terms  long  and  short  skull  and  the  intermediate 
mesocephalic  skull.     A  so-called  cranial  index  has  been 


MEASUREMENTS   OF   THE   SKULL.  143 

introduced,  the  value  of  which  is  expressed  in  figures  when 
the  transverse  diameter  is  multiplied  by  100,  and  the 
product  divided  by  the  longitudinal  diameter.  Finally, 
the  inclination  of  the  profile  line,  pf,  to  the  horizontal 
plane  may  be  utilized  in  order  to  determine  the  profile 
angle  P.  When  this  angle  is  much  less  than  a  right 
angle,  the  individual  is  called  prognathous,  and  orthogna- 
thous  when  the  angle  approaches  a  right  angle.  Progna- 
thism is  almost  always  associated  with  premature  cessa- 
tion of  the  growth  of  the  sphenoid  and  ethmoid  bones, 
and  hence  indicates  a  so-called  sphenoidal  kyphosis,  with 
which  cretinic  deformities  are  apt  to  be  combined. 

The  following  are  the  average  measurements  in  the  liv- 
ing subject : 

Man.  Woman. 

Straight  longitudinal  diameter 18  cm.  17.5  cm. 

Greatest  transverse  diameter 15  14 

Ear  height 11  10. 5 

Distance  between  the  zygomatic  processes..   11  11 
Distance  between  the  auditory  foramina.  ..  12.5                   11.5 
Horizontal  circumference  (measured  through 
the  eDds  of  the  greatest  longitudinal  diam- 
eter)    55                       53 

Sagittal  circumference  (from  the  root  of  the 
nose  to  the  external  occipital  protuber- 
ance)    35  33 

Profile  angle : 

Prognathous 82° 

Orthognathous 83°-90° 

100  X  width 
Length,  width,  index  =  leDgth — 

Dolichocephaly    (long  skull) 

up  to 75 

Mesocephaly 75-80 

Brachycephaly    (short  skull)   80-85 

In  addition  we  may  take  the  following  measures,  which 
show  particularly  the  differences  between  the  anterior  and 
posterior  halves  of  the  skull,  while  the  lateral  differences 
are  found  by  comparing  the  lateral  semi-circumferences 
taken  separately. 


144  HANDBOOK    OF   INSANITY. 


Woman. 


Auriculo-occipital   line    (from   the  anterior 

border  of  one  mastoid  processto  the  other 

over  the  external  occipital  protuberance) .  24  cm.  22  cm. 

Auriculo-frontal  line  (from  the  anterior  rim 

of  one  auditory  foramen  to  the  other  across 

the  glabella) 30  28 

The  various  points  to  which  we  have  referred  as  neces- 
sary to  a  comprehensive  psychiatric  examination  do  not 
complete  the  list.  For  example,  the  peculiarities  of  speech 
and  writing  must  be  carefully  noted.  Writings  may  be 
very  important  when  it  becomes  necessary  to  arrive  at  a 
conclusion  without  seeing  the  patient.  It  is  a  very  com- 
mon fact  that  patients  who  are  able  to  conceal  their  con- 
dition during  conversation,  freely  reveal  their  morbid 
ideas  in  letters. 

A  single  personal  examination  may  suffice  to  determine 
whether  the  patient  must  be  removed  to  an  asylum  or 
whether  he  may  be  treated  at  home,  but  it  is  insufficient 
for  a  complete  psychiatric  examination,  and  in  difficult 
cases  prolonged  observation  is  necessary.  In  doubtful 
cases  the  asylum  is  the  proper  place  for  protracted  obser- 
vation, because  the  trained  attendants  supplement  the 
personal  observations  of  the  physician. 

The  second  point  in  diagnosis,  i.e.,  whether  the  psychical 
disorder  is  independent  or  dependent  upon  another  cere- 
bral disease,  can  also  be  ascertained  with  certainty  only 
after  careful  continued  clinical  observation.  Mistakes 
have  occurred  in  cases  of  drunkennesss,  typhoid  fever, 
acute  meningitis,  and  poisoning.  As  a  rule,  drunkenness 
is  easily  recognized  by  the  odor  of  the  breath,  the  speech, 
and  the  tottering  gait,  but  in  many  cases  there  is  great 
similarity  to  mental  disorder.  In  fact,  drunkenness  is 
really  an  artificial  insanity.  In  it  we  may  find  indica- 
tions of  all  forms  of  insanity,  from  slight  melancholia  to 
complete  inhibition  of  the  mental  functions,  such  as  is 
observed  in  idiocy.  There  may  also  be  conditions  of  ex- 
citement in  which  the  bodily  and  mental  activities  are  in- 


RECOVERY   FROM   INSANITY.  145 

creased.  Increased  self -consciousness  and  impulse  to  move- 
ment remind  us  of  mania,  boastful  speeches  made  with 
a  stammering  tongue  may  make  the  differentiation  from 
similar  phenomena  in  general  paresis  almost  impossible. 
The  resemblance  may  be  still  greater  when,  on  account  of 
a  special  predisposition,  the  intoxication  develops  as  a 
rapidly  subsiding  mania.  Sometimes  drunkenness  acts 
as  the  immediate  exciting  cause  of  permanent  insanity. 
As  a  matter  of  course,  the  differentiation  is  impossible 
when  an  insane  individual  becomes  drunk.  Usually  the 
symptoms  of  drunkenness  are  then  very  violent  or  a  very 
small  amount  of  alcohol  suffices  to  produce  intoxication,  as 
the  majority  of  the  insane  are  very  susceptible  to  alcohol. 
Typhoid  fever  sometimes  begins  with  the  symptoms  of 
a  maniacal  attack  with  great  excitement,  at  other  times 
with  symptoms  of  melancholia.  When  mental  disturb- 
ances begin  unexpectedly,  the  suspicion  of  typhoid  fever 
should  be  kept  in  mind,  especially  in  young  people  and 
when  the  disease  is  epidemic.  In  a  few  days  the  fever 
and  other  symptoms  will  clear  up  the  diagnosis. 

2.  Diagnosis  of  Recovery. 

This  problem  is  especially  difficult  in  individuals  who 
suffered  from  feeble-mindedness  or  hereditary  taint  before 
the  onset  of  the  psychosis  proper. 

The  difficulty  resides  chiefly  in  the  fact  that  the  symp- 
toms which  are  proof  of  the  disease  have  subsided,  but  not 
disappeared  entirely,  and  are  apt  to  return  under  slight 
provocation  amid  different  surroundings.  For  this  reason 
the  judgment  of  the  relatives  is  often  more  decisive  than 
that  of  the  asylum  physician  because  the  restoration  of  the 
previous  personality  is  better  recognized  by  them.  We 
must  here  take  into  consideration  the  possibility  that  pa- 
tients may  conceal  material  symptoms  of  their  disease. 
Hallucinations  and  delusions  which  the  patient  knows  are 
regarded  as  morbid  by  the  physician  are  sometimes  con- 
cealed by  him,  in  order  to  secure  his  discharge  from  the 
asylum  or  from  treatment.  This  dissimulation  may  be 
10 


146  HANDBOOK   OF   INSANITY. 

skilfully  practised  by  patients  in  whom  the  original  affect 
has  disappeared.  But  we  will  either  be  able  to  detect  an 
antagonism  between  the  patient's  speech  and  actions,  or 
the  careful  observation  of  the  former  course  of  the  disease 
and  the  previous  life  of  the  patient  will  confirm  any  doubt 
concerning  the  simulated  recovery.  In  other  cases  only 
the  discharge  from  the  asylum  will  show  the  dissimulation 
by  the  irrational  acts  which  soon  make  their  appearance. 
The  dissimulation  is  very  dangerous  in  suicidal  melan- 
cholies who  sometimes  conceal  their  morbid  feelings  and 
ideas  with  great  skill.  This  danger  is  to  be  kept  in  view, 
particularly  when  the  tendency  to  suicide  has  been  mani- 
fested several  times  in  the  family.  It  may  be  very  impor- 
tant in  such  cases  to  see  the  patient's  letters,  in  which  he 
often  discloses  his  most  secret  thoughts.  At  times,  also, 
the  written  characters  may  reveal  the  attempt  at  dissimu- 
lation. 

It  is  sometimes  very  important  to  determine  whether 
insanity  is  real  or  simulated.  This  may  even  come  into 
question  in  non- judicial  cases.  In  imbecile  and  hysterical 
insane,  in  particular,  there  is  sometimes  a  tendency  to 
exaggerate.  Although  the  intentional  deception  can  usu- 
ally be  recognized,  it  is  more  difficult  to  exclude  the  really 
coexisting  mental  disorder.  The  matter  becomes  still 
more  complicated  from  the  fact  that  simulation  is  practised 
chiefly  in  those  forms  of  insanity  which  develop  upon  an 
hereditary  basis  in  the  form  of  degeneration,  and  hence 
per  se  exhibit  numerous  deviations  from  the  ordinary  clin- 
ical histories.  Simulation  is  practised  in  the  main,  how- 
ever, by  criminals  who  desire  to  avoid  punishment.  But 
the  malingerer  grows  tired  of  his  role  so  much  the  more 
readily  as  exaggeration  of  the  individual  symptoms  is  one 
of  his  most  common  mistakes.  Such  deception  is  easily 
discovered  in  an  asylum,  and,  hence,  doubtful  cases  should 
be  sent  to  an  institution.  Here  the  observation  of  undis- 
turbed sleep  is  easily  made,  and  therefore  conditions  of 
excitement  are  more  rarely  simulated.  Another  mistake 
is  the  combination  of  different  forms  of  disease — for  exam- 


SIMULATION.  147 

pie,  melancholia  and  epilepsy,  which  are  not  often  associ- 
ated in  reality.  The  malingerer  is  apparently  irrational  and 
gives  entirely  wrong  answers,  but  it  is  apparent  that  he  is 
able  to  follow  the  conversation,  because  he  soon  manifests 
a  symptom  which  the  physician  had  referred  to  as  want- 
ing. It  is  especially  difficult  for  him  to  imitate  the  phys- 
ical concomitants  of  a  psychosis — for  example,  the  loss  of 
weight. 

The  physican  should  always  avoid  answering  the  ques- 
tion, so  often  put  by  the  judiciary,  as  to  the  responsibility 
of  a  patient,  and  should  confine  himself  strictly  to  the 
question  of  mental  health  or  disease.  The  question  of 
responsibility  must  then  be  determined  by  the  legal 
authorities. 

C.    THE  BORDER   LINES   OF   INSANITY. 

These  innumerable  disorders  of  the  mind  and  of  ethical 
feelings  must  be  considered  from  a  common  standpoint, 
viz., that  of  degeneration,  which  in  the  majority  of  cases  is 
inherited  or  congenital,  and  is  much  more  rarely  acquired. 

Among  the  many  expressions  of  mental  taint  we  have 
already  described  a  series  of  imperative  conditions,  and 
among  these  we  will  again  refer  to  agoraphobia,  or  fear  of 
places.  It  is  almost  always  associated  with  other  condi- 
tions of  fear,  which  develop  after  mental  and  bodily  strain 
upon  the  basis  of  a  morbid  predisposition  of  the  nervous 
system.  The  peculiar  so-called  "gruebelsucht,"  which  is 
very  often  associated  with  fear  of  contact,  is  also  not  an 
independent  disease,  but  is  based  on  a  morbid  predis- 
position that  is  shown  by  other  mental  and  bodily  symp- 
toms. But  it  is  rarely  possible  to  demonstrate  such  con- 
ditions as  part  of  a  pronounced  psychosis  (particularly 
paranoia) ;  we  must  be  satisfied  with  the  demonstration  of 
the  morbid  predisposition  which  stands  on  the  border  line 
of  insanity. 

The  desire  for  food,  and  especially  for  sexual  gratifica- 
tion, which  also  belong  to  healthy  life,  may  occur  impera- 
tively in  certain  border  conditions,  the  morbid  basis  of 


148  HANDBOOK   OF   INSANITY. 

which  is  often  difficult  of  demonstration  by  the  physician.  • 
This  is  only  possible  when  he  finds  an  hereditary  morbid 
predisposition  in  the  mental  and  physical  development  of 
the  individual.  There  is  also  another  series  of  symptoms 
known  as  the  impulse  to  commit  suicide,  to  steal,  to  drink, 
and  to  commit  arson,  but  these  impulses  do  not  exist  inde- 
pendently of  other  mental  disturbances.  All  these  impulses 
can  only  be  understood  after  the  following  psychological 
considerations.  In  every  healthy  individual  there  is  an 
impulse  to  action  as  the  result  of  the  internal  vital  pro- 
cesses. As  a  rule,  quiet  reflection  and  conscious  selection 
furnish  the  direction  of  his  acts.  But  as  a  man  who  is 
taking  a  walk,  for  example,  strikes  the  weeds  with  his 
cane,  so  there  are  hundreds  of  outlets  to  this  unem- 
ployed impulse  to  activity  in  acts  of  no  moment,  provided 
there  is  no  opposing  stimulus.  By  means  of  antagonistic 
notions  of  decency  and  propriety  the  mentally  healthy 
individual  regulates  any  pronounced  feelings  which  de- 
velop out  of  healthy  vital  processes.  The  mentally  feeble 
individual  yields  to  them  without  reflection.  Hence  in 
many  cases  we  have  to  deal,  not  with  increased,  but  with 
unrestrained  impulses.  If  a  patient  in  an  asylum  steals 
his  neighbor's  bread,  this  will  not  be  called  an  impulse  to 
steal,  because  it  is  merely  a  trivial  satisfaction  of  his  de- 
sire ;  if  an  insane  passionate  smoker  takes  cigars  wherever 
he  finds  them,  he  follows  a  well-grounded  impulse.  The 
unconcealed  exhibition  of  tendencies,  passions,  and  vices  is 
then  not  a  phenomenon  of  disease,  but  is  merely  manifested 
on  account  of  the  disease.  Such  insane,  in  whom  the 
resistance  arising  from  the  sense  of  duty  and  rational  re- 
flection is  wanting,  can  be  led  to  commit  crimes  at  the 
slightest  impulse. 

It  is  difficult  to  distinguish  normal  from  morbid  impulses 
in  the  insane,  because  the  latter,  still  more  than  the  healthy 
individual,  is  seized  by  affects  and  his  actions  are  thus  deter- 
mined. It  is  often  difficult  to  decide  to  what  extent  revenge, 
fear,  homesickness,  or  thoughtlessness  have  led  to  an  act  of 
violence.     It  is  only  when  insanity  can  be  excluded,  that 


ECCENTRICITY.  149 

their  full  significance  may  be  attributed  to  these  affects. as 
normal  motives  of  action.  Otherwise  the  physician  must 
demonstrate  that  morbid  condition  of  the  mind,  on  the  basis 
of  which  the  unbridled  or  morbidly  intensified  impulse  has 
found  expression.  It  may  be  said  that  these  impulsive 
conditions  are  part  of  a  psychosis  and  are  not  on  the 
border-line.  The  incendiary  impulse,  in  particular,  is 
often  regarded  as  an  independent  disease,  but  its  morbid 
character  is  only  determinable  when  an  organic  taint  of 
some  kind  is  present.  This  is  often  facilitated  by  the 
fact  that  the  incendiarism  occurs  so  often  at  the  period  of 
puberty.  Here  the  obscene  impulse  of  the  sexual  devel- 
opment is  added  to  the  others  which  arise  from  the  inter- 
nal vital  processes,  and  finds  its  relief  in  a  manner  which 
is  often  surprising  to  the  individual  himself.  The  proof 
is  most  difficult  in  the  milder  grades  of  feeble-mindedness, 
whose  signs  occasionally  consist  only  of  morbid  irrita- 
bility, stubbornness,  conceit,  lying,  etc.  Hence,  an  opin- 
ion concerning  such  young  incendiaries  not  infrequently 
requires  prolonged  observation.  Girls  are  affected  in  this 
way  somewhat  more  frequently  than  boys. 

Another  group  of  morbid  conditions  which  stand  on  the 
border-line  of  insanity  is  exemplified  by  eccentric  indi- 
viduals. These  include  adventurers,  who  often  change 
their  abode  without  reason,  and  take  long  journeys.  A 
periodical  course  of  the  vagrant  tendency  and  its  accom- 
panying symptoms  is  often  more  or  less  marked.  Some 
of  these  restless  wanderers  finally  end  in  an  asylum. 
Many  remain  free  from  restraint,  but  are  in  constant  con- 
flict  with  established  public  order.  Certain  spendthrifts 
belong  to  this  class,  but  their  condition  can  only  be  re- 
garded as  morbid  when  degeneration  can  be  traced 
throughout  their  entire  development. 

In  some  degenerative  conditions  the  elements  of  allied 
forms  of  insanity  can  be  recognized,  although  the  boun- 
daries of  insanity  are  not  overstepped.  Some  individuals, 
apart  from  a  few  peculiarities,  show  no  signs  of  mental 
disorder  to   their  family  for   many  years.      Then   some 


150  HANDBOOK   OF  INSANITY. 

trivial  insult  becomes  the  starting-point  for  constant  com- 
plaints. Their  obstinacy  on  this  point  soon  becomes 
striking,  and  as  they  make  themselves  disagreeable  on 
this  account,  fresh  food  for  further  complaints  is  furnished. 
Real  delusions  and  hallucinations  are  wanting,  and  a  sys- 
tem of  delusions  does  not  always  develop  out  of  such  con- 
ditions. In  very  few  cases  a  progressive  course  terminat- 
ing in  imbecility  is  observed.  Litigious  and  quarrelsome 
persons  may  become  veritable  thorns  in  the  flesh,  but 
the  morbid  basis  is  rarely  recognized.  It  is  onty  when 
the  impulsive  thirst  for  lawsuits  and  quarrelling  threatens 
to  destroy  fortune  and  happiness,  that  the  eyes  of  the  rela- 
tives are  opened  to  the  existence  of  a  mental  disorder. 

Religious  enthusiasm  and  fanaticism  often  stand  on  the 
border-line  of  insanity.  The  great  majority  of  such  indi- 
viduals suffer  from  hereditary  taint. 

D.    POST-MORTEM   FINDINGS. 

These  possess  very  little  value  as  an  aid  in  the  confir- 
mation of  diagnoses  in  psychiatry.  If  the  diagnosis  can- 
not be  made  during  life,  the  autopsy  will  hardly  ever  aid 
in  arriving  at  a  conclusion.  Even  the  distinct  findings 
in  certain  forms  of  imbecility  merely  justify  the  assump- 
tion that  some  psychosis  has  run  its  course.  At  the  most, 
extensive  atrophy  of  the  convolutions  of  the  frontal  lobes 
point  to  dementia  paralytica,  and  extensive  defects  in 
the  brain  render  a  previous  idiocy  probable.  Even  a  mi- 
croscopical examination  is  not  entirely  demonstrative.  If 
the  psychosis  has  been  observed  during  life,  then  all  the 
findings  in  the  brain  become  important,  especially  diffuse 
changes  in  the  cortex.  Functional  disturbances,  includ- 
ing those  associated  with  congestion  or  anaemia,  usually 
leave  no  traces. 


VI. 

THE   TREATMENT    OF    INSANITY. 
A.    PSYCHICAL   TREATMENT. 

The  physical  basis,  especially  the  brain  and  central  ner- 
vous system,  is  only  involved  to  a  certain  degree  in  men- 
tal disorders,  even  in  the  most  pronounced  cases.  Only 
in  so  far  as  there  is  a  change  in  the  psychophysical  appa- 
ratus may  we  expect  to  exert  an  influence  on  the  course 
of  the  disease  by  suitable  treatment.  All  other  bodily 
changes,  so  far  as  they  influence  the  mental  condition,  are 
important  points  of  attack  in  treatment.  Bodily  and  men- 
tal treatment,  however,  must  always  go  hand  in  hand.  In 
determining  the  limits  beyond  which  psychical  treatment 
loses  its  efficiency,  it  must  be  remembered  that  voluntary 
thought  in  concepts  is  not  dependent  immediately  upon 
the  psychophysical  mechanism,  while  all  emotions  are 
intimately  connected  with  it.  The  latter  may,  therefore, 
be  influenced  immediately,  the  former  only  through  the 
medium  of  the  emotions.  As  all  psychical  processes  are 
associated  more  or  less  with  emotions,  a  large  field  remains 
for  psychical  treatment,  especially  in  recent  cases. 

It  is  evident  that  every  attempt  to  refute,  by  means  of 
reason,  a  patient's  delusions  must  be  useless,  nor  can  we 
exert  an  immediate  influence  upon  his  will. 

But  much  can  be  effected  by  influencing  his  emotions 
and  moods,  both  as  regards  the  latter,  and  also  the  higher 
psychical  processes  dependent  upon  them.  Experience 
teaches,  however,  that  even  the  immediate  influence  upon 
the  moods  is  limited,  and  that  often  we  can  merely  keep 
away  new  injurious  influences.  Many  excitements  and 
exacerbations  may  be  produced  by  rousing  the  feelings, 

151 


152  HANDBOOK   OP   INSANITY. 

and  hence  can  be  avoided  by  a  friendly  and  equable 
demeanor. 

The  personality  of  the  physician  plays  the  principal  part, 
and  by  his  sympathy,  freedom  from  bias,  and  quiet  deci- 
sion he  must  increase  the  ascendency  which  he  has  already 
gained  from  the  correct  judgment  of  the  case.  The  influ- 
ence of  the  physician's  personality  upon  the  insane  is  es- 
pecially evident  outside  of  asylums,  while  the  latter  possess 
powerful  auxiliary  aids  in  treatment.  In  an  asylum  the 
visits  of  the  physician  exert  a  continued  effect  upon  the 
patient,  because  all  the  regulations  of  the  institution  prove 
to  him  that  the  physician  is  at  the  helm. 

For  this  reason  an  asylum  is  the  proper  place  for  those 
patients  who  at  first  resist  treatment.  Sometimes  a  hos- 
pital will  suffice  temporarily,  because  the  influence  of  the 
physician  is  much  greater  than  when  the  patient  is  living 
at  home.  For  the  present  we  will  consider  chiefly  the 
period  during  which  the  patient  has  not  entered  an  asy- 
lum. We  desire  to  influence  his  mood ;  for  this  purpose 
the  surroundings  must  be  sympathetic,  the  patient's  inter- 
est must  be  aroused  and  diverted  from  the  causes  of  the 
disease.  This  is  generally  possible  when  we  bear  in  mind 
that  violent  affects  require  treatment  in  asylums,  while 
the  milder  cases,  which  are  amenable  to  this  form  of  treat- 
ment, require  the  advice  of  the  practitioner.  The  laity 
are  inclined  to  look  for  a  cure  in  distractions.  While  it 
cannot  be  denied  that  conversation,  the  theatre,  and  con- 
certs occasionally  cause  relief,  this  is  generally  so  fleeting 
that  the  family  soon  recognize  the  self-deception.  Even 
the  temporary  improvement  disappears  as  soon  as  the  pa- 
tient recognizes  the  object  of  the  distraction.  At  all 
events  it  is  dangerous  to  subject  a  fresh  psychosis  to  con- 
stant bodily  and  mental  restlessness  engendered  by  frequent 
amusements  and  journeys.  We  must  urgently  caution 
against  bringing  such  a  patient  in  contact  with  new  stim- 
uli. If  he  cannot  remain  longer  in  tne  family,  he  should 
enter  an  asylum.  Only  older  forms  of  disease,  which  are 
lacking  in  affects,  will  be  aided  by  such  distractions. 


OCCUPATION.  153 

The  best  distraction  for  all  is  moderate,  regulated  occu- 
pation, and  preferably  in  the  patient's  own  calling,  if  this 
has  not  been  the  cause  of  the  disease.  Tendencies  and 
habits  are  often  inseparably  united  with  the  occupation. 
Hence  women  suffer  particularly  from  removal  from  home, 
and  we  should  avoid  losing  time  in  travel,  etc.,  if  it  is 
impossible  for  them  to  remain  in  the  family. 

When  this  is  no  longer  possible  the  alienist  must  adopt 
other  principles  in  treatment  in  an  asylum.  In  the  be- 
ginning, at  least,  our  object  must  often  be  to  remove  the 
patient  from  the  action  of  those  daily  irritants  which  are 
often  exercised  upon  him  in  his  business,  in  the  cares  of 
self-support,  in  the  irrational  conduct  of  his  relatives,  and 
often  in  violent  reproaches.  In  recent  cases  it  is  then 
always  better  for  a  time  to  break  off  all  communication 
with  the  family  in  order  to  avoid  emotional  excitement. 
As  a  rule,  visits  from  members  of  the  family  are  only  use- 
ful during  convalescence.  As  a  matter  of  course,  this  is 
not  true  of  chronic  conditions  and  of  the  free  intervals  of 
a  periodical  affect.  In  such  cases  visits  cheer  the  monoto- 
nous life  of  the  patient.  These  remarks  also  hold  good  of 
communications  in  writing. 

But  here,  as  everywhere  in  psychiatry,  we  must  indi- 
vidualize, and  the  treatment  must  be  changed  according 
to  the  special  individuality  of  the  patient.  Hence  the 
great  importance  of  a  knowledge  of  the  previous  life  of  the 
patient. 

It  is  evident  that  psychical  treatment  must  consist,  in 
great  part,  of  the  avoidance  of  injurious  influences.  The 
view  is  still  widespread  that  not  alone  should  we  avoid 
opposing  the  patient,  but  that  we  should  express  assent  to 
his  fears,  tendencies,  and  particularly  to  his  delusions.  In 
many  cases  this  is  injurious ;  fears  of  an  obscure  nature 
may  be  rapidly  converted  into  firm  delusions  and  the  pa- 
tient's own  doubts  may  be  removed.  A  contradictory 
opinion  should  be  expressed  cautiously  in  order  to  avoid 
dispute,  and  in  general  the  morbid  concepts  should  be  dis- 
cussed as  little  as  possible.     The  patient  should  be  told 


154  HANDBOOK   OF   INSANITY. 

frankly  that  he  is  regarded  as  sick,  and  he  should  be 
treated  with  uniform,  friendly  patience  and  quiet  sympa- 
thy. In  other  ways,  also,  frankness  is  the  only  proper 
method ;  deception  is  generally  as  bad  as  force.  If  a  pa- 
tient is  to  be  taken  to  an  asylum,  deception  and  artifice 
are  harmful,  because  they  give  rise  to  distrust  of  the  fam- 
ily and  the  physician.  A  quiet,  but  firm  declaration  that 
the  disease  necessitates  such  a  measure  will  generally  make 
the  employment  of  force  unnecessary.  As  a  matter  of 
course,  it  may  be  unavoidable  in  conditions  of  violent 
excitement  and  great  impairment  of  consciousness. 

As  a  rule,  religious  communications  should  not  be  per- 
mitted in  recent  cases ;  in  permanent  cases  it  may  often 
be  allowed  and  is  occasionally  even  desirable. 

B.    PREVENTION   OF   INSANITY. 

The  prevention  of  insanity  presupposes  an  accurate 
knowledge  of  its  causes,  the  most  prominent  of  which  is 
heredity.  Here  we  may  refer  to  the  question  of  the  mar- 
riage of  the  insane  or  of  those  suffering  from  an  hereditary 
taint.  The  fact  that  unmarried  individuals  are  relatively 
more  liable  to  insanity  than  the  married,  has  sometimes 
led  to  an  affirmative  answer  to  this  question.  The  rare 
cases  in  which  marriage  has  appeared  to  prevent  the  out- 
break of  insanity  do  not  justify  us  in  recommending 
marriage  generally  under  such  circumstances.  On  the 
other  hand,  the  repression  of  long-standing  love  may  cause 
still  greater  injury  to  an  individual  in  danger  of  becoming 
insane. 

The  physician  must  also  consider  whether  the  marriage 
in  view  entails  danger  of  the  propagation  of  mental  and 
allied  nervous  disorders  to  the  offspring.  If  the  other 
partner  is  healthy  and  belongs  to  an  undoubtedly  healthy 
family,  then  the  affection  and  other  circumstances  should 
decide,  provided  that  no  decided  mental  disorder  has  yet 
developed.  But  if  the  other  partner  also  suffers  from 
hereditary  taint,  the  physician  should  decidedly  oppose 
the  marriage.     The  danger  appears  to  be  greatest  when 


EDUCATION.  155 

inebriety  is  associated  with  other  nervous  disorders.  The 
question  of  marriage  may  also  arise  after  recovery  from 
an  attack  of  insanity,  or  after  decided  improvement  of  the 
more  violent  symptoms.  If  recovery  has  lasted  for  several 
years  after  a  single  attack  and  both  parties  have  no  hered- 
itary taint,  marriage  may  be  allowed.  If  the  recovery  is 
questionable  and  only  one  of  the  parties  has  an  hereditary 
taint,  it  should  be  opposed  unqualifiedly.  I  would  also 
advise  against  marriage  when  the  recovery  is  questiona- 
ble, even  if  there  is  no  hereditary  taint  on  either  side. 

It  is  also  the  function  of  the  physician  to  guard  against 
the  development  of  germs  of  the  disease  during  childhood 
and  youth,  or  to  prevent  its  development  when  hereditary 
taint  is  present.  This  is  done  by  carrying  out  the  gener- 
ally recognized  principles  of  hygiene  and  a  careful  course 
of  education.  Special  precautions  are  necessary  at  the 
period  of  puberty,  and  aberrations  of  the  sexual  impulse 
must  be  carefully  watched.  If  the  congenital  or  acquired 
taint  becomes  more  distinct,  unusual  attention  must  be 
paid  to  the  choice  of  a  calling.  We  must  warn  against 
any  occupation  which  requires  great  strain  or  exciting 
responsibility ;  a  uniform  activity  remote  from  the  tumult 
of  a  large  city  may  maintain  the  tottering  equilibrium  of 
the  threatened  individual.  A  special  danger  attaches  to 
the  abuse  of  alcohol. 

C.    BODILY   TREATMENT. 

1.   General  Standpoint  and  Modes  of  Treatment. 

The  principle  of  rest  and  the  prevention  of  new  injuri- 
ous influences  holds  good  for  the  bodily  as  well  as  the 
psychical  treatment.  We  can  merely  remove  the  causes 
or  ameliorate  the  existing  symptoms  of  the  disease.  Dis- 
orders of  the  female  sexual  organs  must  be  cautiously 
examined  and  treated,  because  much  injury  may  be  done 
in  this  direction.  It  must  be  remembered,  however,  that 
the  recognition  of  bodily  diseases  in  the  insane  is  often 
extremely  difficult,  because  many  patients  say  very  little 


156  HANDBOOK   OF   INSANITY. 

or  nothing  concerning  their  sensations.  Hence  the  most 
careful  objective  examination  of  all  organs  must  be  a 
preliminary  to  bodily  treatment. 

The  former  practice  of  venesection  has  now  been  aban- 
doned in  great  part,  but  in  violent  cerebral  congestion,  in 
recent  as  well  as  protracted  conditions  of  excitement, 
rapid  improvement  may  follow  venesection.  In  such  con- 
ditions, as  a  rule,  an  equal  effect  is  produced  by  local 
abstractions  of  blood  (cupping  and  leeches),  especially  as 
their  repeated  application  causes  a  more  permanent  effect. 
As  a  general  thing,  however,  the  insane  should  be  deprived 
of  as  little  blood  as  possible. 

In  anaemia  we  can  sometimes  increase  the  supply  of 
blood  to  the  brain  by  strengthening  the  heart's  action, 
especially  by  the  moderate  use  of  alcoholic  drinks. 

Rest  in  bed  is  also  important  for  the  proper  supply  of 
blood  to  the  brain,  and  possesses  so  many  other  advantages 
that  it  should  be  employed  in  all  recent  cases.  It  protects 
against  loss  of  heat  and  strength,  it  keeps  irritating  sen- 
sory impressions  remote,  and  offers  the  patient  bodily  and 
mental  rest.  Anaemic  and  feeble  patients,  who  exhaust 
their  powers  by  constantly  running  about,  usually  show 
considerable  improvement  soon  after  taking  to  bed.  In 
addition,  the  diet  should  be  nourishing,  but  non-irritating. 

Rest  in  bed  can  always  be  carried  out  in  private  prac- 
tice (except  in  cases  of  violent  excitement,  which  belong 
in  an  asylum) ,  but  external  conditions  often  prevent  the 
employment  of  lukewarm  baths,  which  are  an  almost 
equally  valuable  remedy  for  the  improvement  of  recent 
cases.  The  uniform  moderate  stimulation  of  all  the  cu- 
taneous nerves  produces  a  refreshing  effect.  Cutaneous 
respiration  increases  after  the  cleansing  of  the  skin,  the 
temporary  dilatation  of  the  cutaneous  vessels  stimulates  the 
circulation,  and  the  general  effect  is  almost  always  quiet- 
ing in  anxious  and  excited  patients.  The  bath  is  gener- 
ally followed  by  increased  appetite  and  a  refreshing  sense 
of  being  tired.  In  insomnia  sleep  can  sometimes  be  secured 
by  prolonged  lukewarm  baths  which,  if  kept  up  for  several 


HYDROPATHIC  TREATMENT.  157 

hours,  should  have  a  temperature  of  28°  R. ;  otherwise 
26-27°  R.  will  suffice.  But  such  prolonged  baths  are 
rarely  pleasant  to  the  patient.  If  it  is  obtained  by  force, 
the  bad  effects  will  appear  in  the  greater  irritability  of 
the  excited  patient. 

Wet  packs  can  only  take  the  place  of  baths  to  a  limited 
extent.  They  should  not  be  applied  more  than  a  few 
hours  because  they  are  inconvenient  and  soften  the  skin. 
They  often  produce  quiet  sleep.  Experience  shows,  how- 
ever, that  cold  water  cures  rarely  produce  a  good  effect  in 
psychoses.  Shower-baths  are  not  curative  measures,  but 
merely  the  remains  of  measures  of  restraint.  Cold  river 
and  sea  baths  are  too  exhausting  in  recent,  fully  developed 
psychoses,  while  they  may  be  advantageous  in  the  allied 
conditions  of  neurasthenic  individuals.  Foot-baths  some- 
times act  well  by  derivation ;  the  addition  of  mustard  or 
faradisation  in  a  warm  foot-bath  increases  the  derivation, 
and  may  act  as  a  sedative  and  produce  sleep.  Cold  com- 
presses to  the  head  cause  temporary  relief  in  rush  of  blood 
to  the  head  and  headache;  an  ice-bag  has  the  same 
effect. 

The  use  of  the  milder  cutaneous  derivatives  is  occasion- 
ally desirable.  Dry  cups,  blisters,  feebly  irritative  plas- 
ters, applied  best  to  the  back  of  the  neck,  may  be  employed. 
All  cutaneous  irritants  which  lead  to  prolonged  suppur- 
ation must  be  avoided.  But  if  a  local  pain  in  the  skull 
continues  for  a  long  time,  we  may  try  to  produce  a  deep 
inflammation  by  the  application  of  tartar  emetic  ointment 
to  the  shaved  scalp,  according  to  Autenrieth's  method ; 
this  is  apt  to  cause  exfoliation  of  splinters  of  bone. 
Good  results  have  been  observed  in  such  cases,  and  the 
absorption  of  adjacent  exudations  within  the  cranium  is 
possible  in  this  way. 

A  similar  resolvent  action  has  been  attributed  to  the 
passage  of  the  galvanic  current  through  the  head,  but  this 
should  only  be  done  by  an  expert.  The  use  of  the  faradic 
current  is  simpler;  its  action  is  generally  stimulating  and 
refreshing.      This  is  especially  true  of  general  faradiza- 


158  HANDBOOK   OF   INSANITY. 

tion,  in  which  one  electrode  is  placed  beneath  the  feet  in 
a  foot-bath,  and  the  other  is  stroked  over  the  body. 

In  cases  of  imperfect  nutrition,  massage  is  sometimes 
used  to  advantage.  Under  certain  circumstances  excessive 
feeding  may  also  be  useful. 

2.  Hypnotics. 

Insomnia  is  characteristic  of  the  development  of  many 
psychoses,  and  its  relief  demands  the  urgent  attention  of 
the  physician.  Apart  from  baths,  this  is  effected  mainly 
by  the  administration  of  hypnotics.  At  the  start  it  is 
advisable  to  produce  sleep,  if  possible,  by  other  means, 
for  example,  heavy  beers  and  wine,  which  often  do  well  in 
anaemic  and  exhausted  individuals.  On  account  of  the 
long  duration  of  most  psychoses,  there  is  danger  that  the 
patient  may  become  addicted  to  certain  hypnotics,  and 
hence  they  should  be  changed  from  time  to  time. 

The  best  hypnotic  is  chloral  hydrate  which,  in  doses  of 
from  two  to  three  grams,  produces  a  quiet  sleep  of  several 
hours,  without  specially  disagreeable  after-effects.  Large 
doses  and  long-continued  administration  should  be  avoided. 
In  diseases  of  the  heart  and  vessels  it  may  lead  to  vascular 
paralyses  and  their  sequelae.  It  is,  therefore,  better  to 
give  smaller  doses  (one  to  two  grams)  combined  with 
morphine.  On  account  of  its  disagreeable  taste,  which  is 
best  concealed  by  adding  succus  liquiritise,  it  is  often  re- 
fused by  the  patient.     It  may  then  be  given  per  enema. 

When  chloral  hydrate  can  no  longer  be  given,  paralde- 
hyde should  be  used.  It  may  be  given  for  a  longer  time 
than  chloral  without  producing  injurious  effects.  At  the 
start  it  is  given  in  doses  of  5.0  gm.,  after  a  time  it  may  be 
increased  to  10.0  gm.  or  more.  The  taste  is  still  more  nau- 
seous than  that  of  chloral.  It  is  concealed  somewhat  by 
adding  one  and  one-half  times  the  amount  of  tinctura 
aurantii  simplex,  and  then  shaking.  The  after-taste  and 
odor  are  extremely  disagreeable  and  sometimes  last  twenty- 
four  hours.  Hence,  it  is  given  occasionally  per  enema 
with  an  emulsion  of  oil. 


HYPODEMICS.  159 

In  many  cases  these  two  excellent  hypnotics  cannot  be 
■employed,  principally  on  account  of  their  bad  taste. 
Among  the  tasteless  hypnotics  we  may  mention  sulfonal. 
This  dissolves  in  water  with  great  difficulty  and  is  almost 
entirely  tasteless,  so  that  it  may  even  be  given  unnoticed 
in  solid  food.  2.0  gm.  sometimes  give  rise  to  dizziness 
which  may  last  quite  a  while ;  it  is  very  efficient  in  divided 
does  of  0.5  gm.  from  two  to  six  times  a  day.  Its  action 
varies  greatly  in  different  individuals.  An  eruption  re- 
sembling that  of  measles  is  observed  occasionally  after  its 
administration.  In  several  old,  marantic  individuals  the 
urine  for  a  long  time  had  a  Burgundy-red  color  and  hae- 
moglobinuria  was  present;  in  one  case  this  disappeared 
after  the  discontinuance  of  the  drug. 

Certain  alkaloids  are  also  employed  as  hypnotics,  chiefly 
by  hypodermic  injection.  We  must  be  guarded  in  their 
employment,  not  alone  on  account  of  the  risk  of  acquiring 
the  habit,  but  also  on  account  of  disagreeable  after-effects. 
Internal  administration  should  first  be  tried,  and  hypo- 
dermic injections  used  only  after  the  former  has  proven 
unsuccessful.  Hyoscine,  given  internally  as  hyoscine 
muriate  in  doses  of  0.001-0.002,  has  no  disagreeable  after- 
effects, but  hypodermic  injections  of  one-half  to  one  mgm. 
not  alone  produce  profound  sleep,  but  also  a  tottering  gait, 
dilatation  of  the  pupils,  dryness  in  the  throat,  and  a  feeling 
of  confusion  in  the  head.  The. sleep  is  not  refreshing,  but 
the  quiet  produced  for  several  hours  is  so  complete  (occa- 
sionally after  a  brief  preliminary  period  of  violent  excite- 
ment) that  it  may  be  utilized,  for  example,  in  overcoming 
the  resistance  of  a  maniacal  patient  to  entering  an  asylum. 
Injections  of  morphine  furnish  a  more  harmless  method 
of  producing  quiet  in  such  cases.  Morphine  is  also  a 
curative  remedy  in  insanity.  Its  effect  in  relieving  pain 
is  the  most  important,  and  it  then  acts  indirectly  as  an 
hypnotic.  Hypodermic  injections  act  more  rapidly,  but 
there  is  less  danger  of  the  morphine  habit  when  the  drug 
is  administered  internally.  In  general  it  may  be  said 
that  injections  act  as  a  temporary  sedative  in  the  most 


1G0  HANDBOOK    OF   INSANITY. 

varied  cases  of  insanity,  but  that  we  may  rarely  convert  this 
into  a  permanent  action  by  methodically  repeated  applica- 
tions. In  circular  insanity,  however,  experience  seems  to 
show  that  it  is  possible,  by  means  of  repeated  injections 
of  larger  doses,  to  interrupt  the  doleful  alternation  of  cheer- 
ful and  depressed  moods.  In  conditions  of  great  weakness 
and  in  strong  excitement,  attended  with  dilatation  of  the 
vessels  of  the  brain,  morphine  is  contra- indicated.  Caution 
is  also  necessary  in  valvular  lesions  of  the  heart.  The 
resulting  nausea  and  vomiting,  which  are  often  annoying 
at  the  start,  soon  disappear.  More  serious  import  attaches 
to  other  after-effects,  such  as  paralysis  of  the  vessels,  with 
or  without  respiratory  paralysis.  The  ordinary  initial 
dose  is  0.015  ctgm.  The  increase  in  the  dose  depends  upon 
individual  circumstances.  Larger  doses  than  four  to  five 
centigrams  should  not  be  exceeded,  and  these  are  only 
reached  after  the  drug  has  been  administered  for  several 
weeks  or  months.  Sometimes  a  sedative  action  may  be 
produced  by  gradually  diluting  the  solution  until  finally 
distilled  water  is  given,  of  course  without  the  knowledge 
of  the  patient. 

The  action  of  opium  is  similar  to  that  of  morphine.  It 
is  generally  believed  that  it  acts  better  than  morphine  in 
the  melancholic  terror  conditions  of  females.  It  is  often 
given  in  anaemia.  The  resulting  constipation  compels  the 
use  of  enemata  and  laxatives.  Its  taste  is  not  pleasant,  so 
that  it  may  be  given  by  enema  or  in  the  form  of  supposi- 
tories. Opium  is  best  given  in  the  shape  of  tincture,  ten 
to  twenty  drops,  two  to  three  times  a  day,  or  in  powder, 
beginning  with  0.03  twice  a  day,  and  rapidly  increasing 
to  several  decigrams  at  a  dose.  It  should  be  discontinued 
gradually,  and  should  not  be  given  in  hypnotic  doses. 

When  the  ordinary  hypnotics  fail  us,  we  may  resort  to 
belladonna,  cannabis  indica,  stramonium,  apomorphine, 
and  the  innumerable  other  similar  preparations. 

The  bromides  are  used  extensively  to  diminish  irritabil- 
ity in  various  directions.  Potassium  bromide  is  chiefly 
used,  and  the  salts  of  sodium  and  ammonium  are  only 


BROMIDES.  161 

useful  in  combination  with  the  former.  It  is  employed 
to  act  directly  on  the  cerebral  cortex  in  epileptic  and  other 
irritative  conditions  of  the  motor  centres,  and  in  periodical 
conditions  of  excitement  which  are  unattended  with  vas- 
cular changes.  Unlike  opium,  the  bromides  act  by  means 
of  chemical  changes  in  the  nervous  tissues.  The  diminu- 
tion of  peripheral  irritative  conditions  of  a  neuralgic  char- 
acter greatly  enlarges  the  field  of  application  of  the  bro- 
mides. They  are  given  in  irritative  conditions  of  the 
sexual  organs  and  also  in  non-peripheral  sexual  irritation ; 
they  are  more  efficient  in  females,  particularly  in  menstrual 
conditions  of  excitement.  But  the  diminution  of  sexual 
excitement  requires  very  large  doses,  and,  after  protracted 
administration,  these  give  rise  to  the  well-known  disa- 
greeable after-effects. 

3.   Treatment  of  Important  Symptoms. 

A  purely  causal  treatment  is  possible  in  very  few  cases 
of  insanity — for  example,  in  febrile  diseases,  S37philis,  dis- 
eases of  the  kidneys,  stomach,  etc.  But  in  the  majority 
we  must  be  content  with  treating  the  most  important 
symptoms  of  insanity. 

Among  the  conditions  attending  insanity  great  prac- 
tical importance  attaches  to  the  refusal  to  take  food.  This 
is  observed  most  frequently  in  melancholia  as  a  result  of 
hallucinations  or  delusions.  The  patients  taste  or  smell 
poison  in  the  food,  or  they  abstain  in  order  to  fulfil  a  vow 
or  because  they  are  unworthy  of  eating.  In  some  the 
abstinence  may  be  due  to  a  desire  to  commit  suicide  or  to 
the  notion  that  the  digestive  organs  are  impermeable.  At 
first  we  must  not  attach  much  importance,  outwardly,  to 
the  patient's  refusal  to  take  food,  because  repeated  and 
urgent  requests  to  eat  may  even  confirm  his  fear  of  poi- 
soning. In  many  cases  hunger  is  our  best  ally.  After  a 
few  days  this  occasionally  becomes  so  great  that  the  pa- 
tient ravenously  devours  the  food  placed  before  him.  In 
many  cases  it  is  well  to  disregard  apparently  the  refusal 
to  take  food,  to  place  the  meals  regularly  before  the  patient, 
11 


162  HANDBOOK   OF   INSANITY. 

and  to  leave  him  alone  with  them  for  some  time.  Many- 
eat  when  they  think  themselves  unobserved.  This  is  more 
apt  to  occur  in  bed,  and  indeed  rest  in  bed  is  the  first  re- 
quisite, in  refusal  to  take  food,  in  order  to  maintain  the 
bodily  strength  and  heat.  Expectant  treatment  must 
vary  with  the  individual  case.  When  consciousness  is 
impaired  and  will-power  diminished,  it  is  often  sufficient 
to  place  the  spoon  to  the  lips  or  to  push  the  food  into  the 
mouth,  whereupon  the  movements  of  mastication  and  de- 
glutition will  occur  in  a  reflex  manner.  Delusions  or 
hallucinations  can  sometimes  be  overcome  temporarily  by 
the  positive  assurance  that  eating  is  permitted,  or  by  a 
quiet  command.  The  fear  of  poisoning  is  sometimes  re- 
lieved by  tasting  the  food.  Some  patients  will  eat  eggs, 
others  take  their  neighbor's  food,  which  appears  to  them 
.innocuous.  But,  as  a  general  thing,  hunger  proves  the 
strongest  incentive.  If  the  patients  drink  water — and 
this  is  often  the  case  even  when  otherwise  there  is  obsti- 
nate refusal  to  take  food — we  may  add  sugar  to  the  water. 
In  fact,  the  drinking  of  water  is  a  reason  for  delaying  the 
apparently  necessary  forced  feeding. 

We  must  also  attempt  to  keep  the  mouth  clean  by  rins- 
ing with  water.  The  treatment  of  an  accompanying  gas- 
tric catarrh  or  constipation  is  sometimes  facilitated  hj 
the  fact  that  the  patients  do  not  resist  the  administration 
of  drugs  whose  preparation  in  the  apothecary  appears  to 
them  to  be  free  from  suspicion.  Enemata  of  water  should 
be  tried,  because  a  sufficient  supply  of  water  causes  less 
danger  from  prolonged  abstinence  from  food. 

With  a  good  condition  of  nutrition  and  rest  in  bed  a 
week  may  be  allowed  to  elapse  before  proceeding  to  forced 
feeding.  Under  favorable  circumstances  we  may  even 
wait  two  weeks  or  more.  But  if  the  complete  refusal  of 
food  has  been  preceded  by  a  prolonged  period  of  imperfect 
nourishment,  or  if  other  exhausting  causes  were  at  work, 
then  artificial  feeding  becomes  necessary  within  a  few 
days. 

The  best  method  is  the  introduction  of  a  tube  into  the 


ARTIFICIAL   FEEDING.  163 

stomach,  either  through  the  mouth  or  nose.  As  the  mouth 
can  be  opened,  in  many  cases,  only  by  brute  force,  the 
introduction  of  the  tube  through  the  nose  is  almost  always 
the  milder  method.  The  soft  nasal  sounds  (Jacques'  pat- 
ent) may  be  highly  recommended.  They  should  have  a 
funnel-shaped  enlargement,  for  the  convenient  reception 
of  the  nutrient  fluids.  As  a  matter  of  course,  the  patient 
must  be  held  firmly  by  one  or  more  persons,  and  this  is 
best  done  during  dorsal  decubitus  in  bed.  The  tip  of  the 
tube  is  made  flexible  by  dipping  it  for  a  short  time  in  hot 
water,  and  is  slightly  curved  in  a  downward  direction. 
The  tube  is  introduced  slowly  and  generally  meets  with 
resistance,  which  is  easily  overcome,  at  the  posterior  phar- 
yngeal wall  and  at  the  level  of  the  larynx.  Although  the 
sound  usually  glides  freely  past  the  larynx,  especially  if 
the  tip  is  not  bent  too  strongly,  the  danger  of  entering  the 
trachea  is  to  be  kept  in  mind  in  patients  who  are  paralyzed 
or  in  whom  severe  disorders  of  consciousness  prevent  vio- 
lent reflex  movements.  A  tolerably  certain  means  of 
ascertaining  whether  the  tube  has  really  entered  the  stom- 
ach, consists  of  auscultation  of  the  organ  while  a  third 
person  is  blowing  air  through  the  sound.  In  the  adult, 
when  the  head  is  bent  backward,  the  distance  from  the 
incisor  teeth  to  the  cardiac  orifice  of  the  stomach  is  forty  to 
forty-four  centimetres  (maximum,  forty-six,  minimum, 
thirty  centimetres) ,  so  that  a  mark  made  upon  the  sound 
will  inform  us  concerning  the  position  of  the  stomach  ex- 
tremity. A  single  feeding  often  suffices  to  make  the  pa- 
tient eat  voluntarily.  Otherwise  the  feeding  must  be  per- 
formed once  or  twice  a  day,  according  to  the  patient's 
strength.  The  entrance  of  the  sound  is  facilitated  by  oil- 
ing it,  by  gently  pushing  it  forward  and  backward.  A 
movement  of  deglutition  facilitates  the  introduction,  and 
may  be  produced  by  pouring  a  few  drops  of  water  into  the 
free  nostril ;  the  patient  then,  in  a  measure,  swallows  the 
sound.  At  first  we  pour  in  only  a  few  drops  of  fluid, 
which  must  be  free  from  clots,  etc.  In  order  to  be  abso- 
lutely sure  we  may  begin  with  a  few  drops  of  water.     At 


164  HANDBOOK    OF   INSANITY. 

the  first  feeding  we  should  give  at  the  most  one-half  litre 
of  the  nutrient  fluid,  in  order  that  the  retracted  stomach 
with  its  insufficient  supply  of  gastric  juice  may  not  be 
overburdened.  Great  difficulty  sometimes  arises  on  ac- 
count of  vomiting,  which  occurs  involuntarily  after  the 
introduction  of  the  fluid.  The  addition  of  a  few  drops  of 
chloroform  or  brushing  the  pharynx  with  cocaine  may  re- 
lieve this  symptom.  We  are  generally  powerless  when 
the  vomiting  takes  place  voluntarily  as  the  result  of  delu- 
sions. Such  patients  also  extrude  nutrient  enemata,  and 
we  must  then  allow  them  to  starve  to  death.  Obstinate 
involuntary  emesis  may  lead  to  the  same  result  because  the 
continued  vomiting  of  the  gastric  contents  alongside  the 
sound  forces  us  to  discontinue  the  artificial  feeding  on 
account  of  the  danger  of  suffocation  or  foreign-body  pneu- 
monias. Sometimes  artificial  feeding  may  be  continued 
for  weeks,  months,  or  even  years. 

Occasionally  we  can  succeed  in  introducing  fluid  food 
in  the  following  simple  manner :  The  patient  is  placed  in 
a  horizontal  position,  the  head  bent  slightly  backward, 
and  held  in  this  position,  unless  the  resistance  is  too  great, 
and  the  fluid  is  then  poured  directly  into  one  nostril.  As 
a  precaution,  we  begin  with  a  little  water,  in  order  to 
begin  the  proper  movement  of  deglutition. 

As  a  general  thing,  forced  feeding  is  impracticable  in 
private  practice,  and  the  patients  requiring  it  should  be 
sent  to  a  hospital  or  asylum.  Indeed  we  are  now  ap- 
proaching the  treatment  of  those  symptoms  which  can 
only  be  carried  out  successfully  in  asylums.  These  in- 
clude, above  all,  the  tendency  to  commit  suicide. 

Such  patients  require  special  supervision  and  may  not 
be  left  alone  for  a  moment.  The  possibility  of  watching 
several  patients  of  this  kind  is  furnished  by  a  ward  in 
which  orderlies  are  on  duty  day  and  night.  In  such  wards 
every  opportunity  for  carrying  out  the  dangerous  tendency 
must  be  wanting.  Nails,  hooks,  projections  on  the  walls 
and  beds,  sharp  instruments  (spoons  should  be  used,  rather 
than  knives  and  forks)  must  not  be  permitted.     The  pa- 


PREVENTION    OF    SUICIDE.  165 

tients  may  not  wear  neckties  or  ribbons.  Some  individ- 
uals are  so  inventive  as  regards  methods  of  committing 
suicide  that  they  must  be  kept  in  a  room  which,  apart 
from  the  bare  walls,  merely  has  windows  (provided  with 
fine  wire  grating  or  with  very  strong  glass)  and  doors 
without  knobs  or  latches.  The  bed  must  be  removed,  and 
even  then  the  patient  may  attempt  to  choke  himself  with 
strips  of  clothing,  or  he  may  run  his  head  against  the 
wall.  The  latter  plan  rarely  proves  fatal,  although  frac- 
tures of  the  skull  and  cervical  spine  have  been  known  to 
follow.  Nothing  then  remains  but  to  confine  the  use  of 
the  hands  by  means  of  leathern  gloves  or  a  strait-jacket, 
together  with  constant  supervision  in  the  "watching 
ward."  In  very  rare  cases  we  are  finally  compelled  to 
tie  the  patient  to  the  bed  or  to  adopt  chemical  restraint, 
i.e.,  to  produce  narcosis  by  injections.  It  is  an  important 
rule,  however,  that  every  patient  who  is  in  mechanical 
restraint  must  be  constantly  watched  in  order  to  prevent 
serious  accident,  as,  for  example,  hanging  by  the  bands  of 
a  loosened  strait-jacket. 

The  tendency  of  the  present  time  is  the  avoidance  of 
all  mechanical  restraint,  and  it  may  be  dispensed  with  if 
the  attendants  are  sufficiently  numerous  and  well  trained, 
and  if  strong  drugs  are  resorted  to.  In  rare  cases,  how- 
ever, it  would  be  fanatical  to  dispense  with  restraint ;  for  ex- 
ample, in  cases  of  severe  injury,  in  restless  patients,  which 
can  only  heal  when  rest  is  enforced.  Or  mechanical  re- 
straint may  be  necessary  in  conditions  of  exhaustion,  be- 
cause drugs  would  still  further  injure  the  exhausted  nervous 
system.  In  incurable  cases  we  may  use  chemical  restraint, 
out  of  deference  to  the  feelings  of  the  family,  but  in  recent 
cases  there  is  danger  of  chemical  injury  to  the  brain.  Fi- 
nally, there  are  cases  of  uncleanliness,  of  smearing  the 
faeces,  in  which  at  least  the  application  of  gloves  becomes 
necessary. 

Filthiness  and  a  tendency  to  destroy  things  often  compel 
us  to  give  the  patients  unusually  tough  clothing,  made 
commonly  of  strong  linen  which  is  fastened  at  the  back. 


166  HANDBOOK   OF   INSANITY. 

Violent  patients  should  use  table  utensils  made  of  papier- 
mache,  with  which  no  serious  damage  can  be  done.  The 
attendants  must  never  be  permitted  to  employ  mechanical 
restraint  without  the  order  of  the  physician. 

D.    ASYLUMS   AND    THEIR   ADVANTAGES. 

A  good  asylum  offers  to  curable  patients  an  advantage 
which  is  not  possessed  even  by  hospitals,  viz.,  the  oppor- 
tunity for  regular  occupation,  especially  in  the  open  air. 
Occupation  is  furnished  in  workshops  and  in  all  house 
arrangements  which  require  cleaning.  Females  find 
sufficient  to  do  in  making  clothes  and  in  attending  to  the 
linen  and  to  the  wash.  The  fact  that  the  physician  pos- 
sesses the  power  of  compelling  obedience  to  his  orders 
greatly  facilitates  mild  treatment.  The  force  of  example 
and  of  the  uncomplaining  obedience  of  a  large  corps  of 
attendants  and  of  numerous  other  patients  usually  prevents 
the  newly  arrived  patient  from  rebelling  against  the  dis- 
cipline. The  time  for  waking  and  sleeping  and  eating, 
of  taking  walks  and  of  working,  is  determined  by  the 
physician,  so  that  a  patient,  who  is  no  longer  able  to  man- 
age himself,  is  forced,  like  the  wheel  of  a  machine,  to  fol- 
low its  course.  Even  violent  forms  of  excitement  often 
disappear  rapidly  in  an  asylum  because  the  patient  rapidly 
learns  that  a  strict,  though  sympathetic  spirit  of  order, 
not  his  morbidly  excited  will,  is  the  ruler,  supported  by 
external  arrangements  against  which  he  is  powerless. 
But  in  the  best  asylums  the  discipline  is  less  effective  than 
the  medical  treatment. 

E.    TREATMENT   OF   CONVALESCENTS. 

There  are  very  many  cases  in  which  the  slow  progress 
of  recovery  and  very  profound,  although  still  morbid, 
homesickness  have  compelled  a  premature  discharge  from 
the  asylum  in  order  to  prevent  the  danger  of  an  exacerba- 
tion or  even  of  suicide.  Under  favorable  conditions  at 
home,  recovery  in  such  cases  usually  is  undisturbed,  but 


CONVALESCENCE.  167 

if  these  conditions  entail  new  cares  and  worries,  a  relapse 
is  soon  unavoidable.  In  such  cases  it  is  the  duty  of  the 
family  physician,  who  is  better  posted  than  the  asylum 
physician,  to  decide  whether  a  return  to  the  former  condi- 
tions of  life  will  be  attended  with  more  serious  results  than 
a  longer  stay  in  the  asylum.  Every  excessive  strain,  such 
as  the  premature  resumption  of  the  former  occupation,  is 
dangerous. 

The  period  of  convalescence  requires  psychical  treat- 
ment which  may  aid  materially  in  accelerating  recovery. 
Any  delusions  which  may  have  been  left  over  may  now 
be  removed  by  friendly  objections,  and  occasionally  by 
light  jests.  Some  feel  the  necessity  of  receiving,  from 
the  physician,  the  constantly  renewed  assurance  of  the 
morbid  nature  of  their  ideas  and  feelings.  Patience, 
sympathetic  insight  into  the  patient's  personality,  yielding 
without  weakness  on  the  one  side,  and' firmness  without 
obstinacy  on  the  other  side,  must  be  the  main  features  of 
the  physician's  activity.  The  disease  is  explained  as  a 
misfortune  that  may  happen  to  any  one,  and  the  doubting 
patient  will  again  acquire  self-confidence  and  trust  in  the 
future.  The  convalescent  follows  the  one  who  understands 
him,  like  a  child  seeking  protection.  The  physician  must 
listen  patiently  to  his  communications,  and  must  for  a 
time  continue  to  be  his  mental  guide.  As  a  matter  of 
course,  the  care  of  the  body  must  not  be  neglected, 


VII. 

HISTORY  OF  PSYCHIATRY. 

A.    ANTIQUITY. 

It  was  the  most  important  result  of  the  works  of  the 
Hippocratic  school  and  its  founder  that,  with  the  recog- 
nition of  the  physical  basis  of  mental  disorders,  the  first 
attempt  was  made  to  withdraw  their  treatment  from  the 
hands  of  the  priesthood.  In  Greece  and  Egypt  patients 
were  received  in  the  temples,  where  the  supernatural  influ- 
ences of  mysterious  powers  were  combated  by  conjurations 
and  magic  remedies.  The  insane  thus  received  protection 
against  external  injurious  influences,  but  it  is  doubtful 
whether  the  treatment  was  otherwise  beneficial.  Mental 
disorders  were  regarded,  as  is  shown  by  the  use  of  the 
term  melancholia  and  the  constant  administration  of  helle- 
bore, simply  as  the  results  of  morbid  bodily  conditions, 
especially  of  changes  in  the  principal  secretions,  such  as 
bile,  mucus,  etc.  For  this  reason  no  sharp  distinction 
was  drawn  between  psychical  diseases  and  diseases  of  the 
brain.  As  a  rule,  febrile  delirium  was  included  among 
the  mental  affections.  The  term  phrenitis  was  applied  to 
all  violent,  especially  febrile,  diseases  which  were  associ- 
ated with  mental  disturbances,  so  that  it  was  approxi- 
mately identical  with  what  was  called  "  nervous  fever"  by 
practitioners  at  the  beginning  of  this  century.  For  ex- 
ample, phrenitis  included  many  cases  of  typhoid  fever  and 
also  the  irritative  cerebral  conditions  of  severe  pneumonias. 

On  the  whole,  the  treatment  of  the  insane  was  non- 
stimulant  and  sedative ;  in  the  feeble-minded  it  was  mainly 
gymnastic.  It  is  a  striking  fact  that  hereditary  predisposi- 
tion was  not  considered  or  mentioned.      Nor  were  the 

168 


THE   HIPPOCRATIC   SCHOOL.  169 

changes  in  the  skull  which  occur  in  the  insane  referred 
to,  while  many  complicated  and  obscure  morbid  condi- 
tions were  properly  interpreted  and  explained.  The  brain 
was  regarded  as  the  site  and  starting-point  of  most  forms 
of  insanity,  although  their  causes  were  sought  in  irrita- 
tion by  bile,  mucus,  and  water. 

The  confusion  of  true  cerebral  diseases,  febrile  general 
diseases  and  psychoses,  also  prevented  an  accurate  differ- 
entiation of  the  various  forms  of  psychical  disease.  For 
example,  the  terms  melancholia  and  mania  were  applied 
mainly  to  insanity  in  general.  In  accordance  with  this 
the  treatment  was  quite  uniform.  The  most  important 
elements  were  cold  and  warm  douches,  rest,  proper  diet, 
and  gymnastic  exercises  in  the  feeble-minded. 

The  prevailing  opinions  among  the  laity  also  agreed 
with  such  views.  How  correct  and,  in  individual  respects, 
profound  were  the  theories  and  investigations  of  the  Hip- 
pocratic  school,  is  evident  from  the  fact  that  much  atten- 
tion was  devoted  to  the  statement  of  Erasistratus  that  the 
area  of  the  surface  of  the  brain  furnishes  a  measure  of  the 
mental  ability ;  in  opposition  to  this  view  the  importance 
of  the  internal  structure  was  maintained. 

The  Roman  law  early  laid  the  foundation  for  the  view 
followed  by  all  subsequent  legal  authorities  that  an  "  in- 
sanus"  may  retain,  under  certain  circumstances,  control 
of  his  affairs,  but  that  a  "furiosus"  requires  guardianship. 
The  decision  concerning  civil  and  criminal  responsibility 
lay  entirely  in  the  hands  of  the  judge. 

Asklepiades  of  Bithynia  (124  B.C.)  was  opposed,  in  a 
measure,  to  the  doctrines  of  the  Hippocratic  school.  In 
addition  to  measures  of  restraint,  he  also  employed  psy- 
chical treatment,  especially  music  as  a  sedative.  He  at- 
tached great  importance  to  baths  and  cold  frictions,  and 
was  less  in  favor  of  venesection  and  confinement  to  dark 
rooms,  which  were  recommended  by  all  his  contemporaries. 

Celsus  made  important  statements.  He  required  that 
the  treatment  should  be  adapted  to  the  peculiarities  of 
each  individual  case.     Baseless  fear  is  to  be  relieved  by 


170  HANDBOOK   OF   INSANITY. 

gentle  speech,  or  by  kind  deceit;  maniacs  can  occasionally 
be  controlled  only  by  blows ;  melancholia  often  yields  to 
strains  of  music.  As  a  rule  the  patient  should  not  be  em- 
bittered by  contradiction.  The  most  important  object  of 
treatment  is  to  secure  sleep ;  poppy  and  henbane  are  es- 
pecially effective. 

Soranus  of  Ephesus,  who  lived  in  Rome  under  the 
Emperors  Trajan  and  Hadrian,  opposed  measures  of  re- 
straint. He  was  also  unreservedly  opposed  to  whipping 
and  to  intentional  intoxication  of  the  patient,  but  favored 
general  and  local  abstraction  of  blood.  He  attached  the 
greatest  importance  to  psychical  treatment,  to  isolation 
under  supervision,  to  the  action  of  light,  and  the  avoidance 
of  irritation. 

Aretseus  of  Cappadocia  soon  after  advanced  the  scien- 
tific side  of  psychiatry.  He  recognized  the  crossed  action 
of  the  nerve  centres.  He  confined  the  term  melancholia 
to  the  conditions  which  are  so  called  at  the  present  time, 
and  regarded  it  as  the  primary  form  from  which  all  others 
develop.  He  furnished  excellent  descriptions  and  consid- 
ered the  causal  conditions,  such  as  social  position,  mental 
work,  and  overwork.  The  chief  importance  in  treatment 
was  attached  to  drugs.  After-treatment  consisted  of 
thermal,  sea,  and  sand  baths,  sea  voyages,  and  a  sojourn 
in  beautiful  countries. 

Galen  (131-201  a.d.)  distinguished  primary  cerebral 
diseases  from  those  which  are  due  to  diseases  of  other 
organs,  and  also  differentiated  phrenitis  from  chronic  dis- 
orders attended  with  depression  or  exaltation. 

These  constitute  the  most  important  steps  in  the  devel- 
opment of  psychiatry  in  ancient  times. 

B.    MIDDLE    AGES   AND    MODERN   TIMES. 

The  decay  of  medicine  during  the  Middle  Ages  allowed 
the  achievements  of  antiquity  in  psychiatry  to  sink  into 
oblivion.  The  knowledge  of  the  physical  basis  of  insanity 
disappeared  more  and  more,  the  old  idea  of  possession 
gained  sway,  and  attempts  at  healing  again  fell  into  the 


INFLUENCE   OF   SUPERSTITION.  171 

hands  of  the  priesthood.  Practical  medicine  maintained  a 
precarious  existence  in  convents.  Superstition  and  relig- 
ious bigotry  struggled  for  the  upper  hand  in  the  treatment 
of  the  insane.  The  devil  was  suspected  everywhere,  and  it 
was  regarded  as  an  act  of  Christianity  to  oppose  him  by 
means  of  prayers  and  exorcism. 

When  violent  and  maniacal  patients  became  too  annoy- 
ing they  were  simply  sent  out  of  the  country.  In  many 
cities  guardians  of  the  insane  were  appointed,  who  were 
responsible  for  their  care,  or  the  family  were  held  respon- 
sible. When  this  could  not  be  done  the  authorities  inter- 
vened, the  expense  being  borne  by  the  family. 

Permission  to  consign  the  patients  to  the  towers  of  the 
city  walls  was  long  regarded  as  an  especial  favor.  Toward 
the  close  of  the  Middle  Ages  the  increasing  number  of 
insane  led  to  the  erection  of  a  special  building  in  Nuern- 
berg. In  other  places,  at  the  most,  a  few  rooms  in  a  hos- 
pital were  fitted  up  wherein  restless  patients  could  be  kept 
in  chains.  Whenever  circumstances  permitted,  the  family 
was  compelled  to  keep  its  insane  members  imprisoned. 
There  were  portable  prisons,  so-called  stocks,  which  could 
be  placed  in  any  room. 

The  notion  of  the  possession  of  the  insane  by  evil  spirits 
prevailed  everywhere.  In  Basle  and  many  other  towns 
maniacs  were  whipped  by  the  hangman  in  order  to  drive 
out  the  evil  spirits.  In  non-excited  conditions  the  symp- 
toms of  the  disease  were  often  regarded  as  sins,  and  were 
treated  accordingly  by  confession,  fasting,  pilgrimages, 
and  self-castigation. 

The  conditions  were  similar  in  other  European  countries 
with  the  exception  of  Spain  and  Italy,  in  which  regular 
insane  asylums  are  found  in  the  last  centuries  of  the  Mid- 
dle Ages. 

The  notion  of  demoniacal  possession  developed  at  this 
time  into  that  of  possession  by  witches.  The  witch  pro- 
cesses were  due  mainly  to  the  prevailing  belief  in  devils 
and  demons,  together  with  the  working  of  the  Inquisition. 

The  influence  of  demonological  views  was  so  great  that 


172  HANDBOOK   OF   INSANITY. 

even  such  distinguished  men  as  Paracelsus  and  Plater  op- 
posed them  very  feebly  with  medical  opinions ;  although 
the  thorough  anatomical  knowledge  of  Plater  brought  him 
nearer  to  a  correct  comprehension  of  insanity  than  Para- 
celsus, who  despised  anatomy.  The  latter  stated,  however, 
that  exorcism  of  the  devil  was  useless,  and  he  attempted 
to  cure  insanity  by  external  cutaneous  irritants,  cathartics, 
and  venesection.  He  regarded  sleep  as  an  important 
auxiliary  and  also  made  suggestions  for  a  sort  of  psychical 
treatment. 

Plater  made  a  rather  obscure  distinction  between  demo- 
niacal possession  and  natural  insanity.  Emotional  ex- 
citement is  to  be  treated  at  first  by  sympathy,  advice,  and 
persuasion,  then  follow  threats  and  blows.  He  recognized 
the  necessity  of  restraint  in  violent  cases,  but  advises  that 
at  times  the  chains  should  be  cautiously  loosened. 

Even  Weyer,  the  most  celebrated  opponent  of  the  notion 
of  witches,  did  not  deny  the  reality  of  the  pranks  of  Satan 
and  did  not  dare  to  attribute  them  to  mental  disease.  He 
merely  attempted  to  restrict  the  assumption  of  magical 
influences  to  rar,e  cases. 

The  influence  of  Luther,  who  was  a  firm  believer  in 
the  devil  and  the  doctrine  of  possession,  long  prevented  a 
proper  appreciation  of  the  trouble  in  Protestant  North 
Europe ;  and  until  a  late  period  in  modern  times  the  in- 
sane were  persecuted  as  sorcerers  and  witches. 

The  hopeless  condition  of  the  insane  who  were  seques- 
tered in  prisons  is  made  clear  by  several  descriptions 
which  have  been  made  known.  Sometimes  they  were  kept 
for  years  in  cells  which  were  destitute  of  doors  and  win- 
dows, with  only  an  opening  in  the  ceiling.  Through  this 
opening  food  and  drink  were  lowered  to  the  patient.  His 
feet  and  hands  were  often  chained  to  the  wall.  Gloves 
with  iron  rings  were  used  to  prevent  suicide. 

A  certain  degree  of  improvement  became  noticeable  in 
the  seventeenth  and  eighteenth  centuries  when  the  insane 
were  admitted  to  houses  of  correction.  Certain  of  the 
prisoners  were  compelled  to  dress,  clean,  and  feed  the  pa- 


MEDICAL   TREATMENT.  173 

tients.  In  exceptional  cases  greater  freedom  was  granted 
to  the  insane,  and  thus  various  measures  of  restraint  be- 
came unnecessary.  As  a  rule,  however,  the  poor  sufferers 
were  neglected,  the  prisoners  mocked  and  gibed  them,  or 
they  were  confined  as  formerly  to  dismal  quarters.  Many 
physicians  regarded  restraint-chairs,  to  which  the  patients 
were  bound,  as  a  mild  measure,  because  it  protected  them 
against  the  blows  and  harsher  measures  of  the  brutal 
turnkeys. 

It  was  not  until  the  beginning  of  this  century  that 
Langerman  advocated  the  medical  treatment  of  the  insane 
in  addition  to  mere  detention.  But  the  treatment  long  re- 
mained a  cruel  one.  In  addition  to  emesis,  repeated  cath- 
arsis, and  cold  douches  with  hundreds  of  pails  of  water, 
rotary  machines  played  an  important  part.  By  means 
of  a  revolving  chair  the  patient  was  rotated  around 
his  vertical  axis  a  hundred  times  a  minute,  and  vomiting 
often  followed.  The  resulting  exhaustion  was  regarded 
as  sedation,  and  such  tortures  were  supposed  to  possess 
indirect  psychical  curative  powers.  It  was  also  thought 
that  patients  could  be  cured  by  placing  them  in  a  closed 
sack.  The  ingenuity  of  physicians  in  inventing  new 
measures  of  restraint  as  curative  remedies  is  hardly  cred- 
ible. 

But  gradually  the  opposition  to  the  view  that  restraint 
is  a  curative  measure  in  psychoses  became  stronger  and 
stronger.  The  remedy  threatened  to  be  more  harmful  than 
its  former  application,  which  was  only  intended  to  render 
the  insane  harmless,  because  the  increasing  number  of  pa- 
tients, and  the  growing  notion  concerning  their  curability, 
increased  the  zeal  of  the  physicians.  The  apparent  sci- 
entific foundation  for  the  employment  of  restraint  long 
preserved  the  system,  although  more  humane  views  every- 
where became  more  prominent. 


174  HANDBOOK    OF    INSANITY. 


C.  GRADUAL  REFORM    OF  PSYCHIATRY  IN  THE    PAST    HUN- 
DRED YEARS. 

1.  Erection  of  Insane  Asylums. 

It  would  be  wrong,  however,  to  overlook  the  fact  that 
along  with  these  imperfections  in  the  treatment  and 
knowledge  of  mental  disorders,  important  works  on  psy- 
chiatry appeared  in  many  countries,  together  with  notable 
improvement  in  the  treatment  and  care  of  the  insane.  We 
cannot  enter  here  into  the  scientific  results.  They  were 
closely  associated  with  the  prevalent  philosophical  doc- 
trines, and  can  therefore  only  be  comprehended  from  a 
knowledge  of  the  latter.  Their  external  expression  was 
found  in  the  external  arrangements,  particularly  the  insane 
asylums,  which  appeared  in  Germany  at  a  comparatively 
late  period.  For  example,  in  1645  a  special  asylum  was 
founded  in  Florence,  and  at  the  beginning  of  this  century 
Chiarugi  of  Italy  carried  out  the  most  humane  principles 
of  treatment ;  he  also  gave  instruction  in  psychiatry.  In 
1681  the  first  independent  asylum  for  the  insane  in  France 
was  built  at  Avignon.  In  1728  the  first  asylum  was  opened 
at  Warsaw;  in  1741,  in  Springfield,  England.  A  little 
later  the  rudiments  of  an  asylum  were  established  in 
Wuerzburg  and  Braunschweig.  In  1751  the  Philadelphia 
asylum  was  inaugurated.  In  the  same  year  the  insane 
patients  of  St.  Luke's  Hospital  in  London  were  divided 
into  curable  and  incurable  cases.  In  German  countries 
very  slow  progress  continued  to  be  made. 

An  illustration  of  the  extent  to  which  some  physicians 
were  in  advance  of  their  contemporaries  is  shown  by  the 
fact  that  in  1804  Glawnigs  proposed  that  an  asylum  be 
erected  in  order  that  the  insane  might  be  enabled  to  do 
farm  work.  At  this  time  Langerman  of  Bayreuth  re- 
sorted extensively  to  occupation  in  the  treatment  of  insan- 
ity, and  employed  mechanical  restraint  only  in  exceptional 
cases. 


ABUSES    OF    TREATMENT.  175 

2.   Opposition  to  Mechanical  Restraint. 

In  France,  Daquin  was  the  first  to  oppose  mechanical 
restraint  in  his  writings,  and  Pinel  was  the  first  who  dis- 
pensed with  it  in  practice.  He  practised  the  treatment  of 
the  insane  in  Paris  in  a  humane  manner,  and  his  writings 
were  epochal  in  the  progress  of  French  psychiatry.  But 
despite  his  efforts  the  treatment  of  the  insane  remained 
very  poor,  so  that  in  1818  Esquirol  reported  to  the  Min- 
istry that  the  unfortunate  insane  were  treated  worse  than 
convicts  and  that  their  condition  was  worse  than  that  of 
beasts. 

In  the  insane  wards  of  thirty-three  cities  he  found  them 
living  in  the  most  damp  and  unhealthy  buildings.  They 
were  clothed  in  rags  and  lay  upon  straw  in  order  to  pro- 
tect themselves  against  the  damp  cold  of  the  floor.  With 
poor  food  and  harsh  treatment,  without  air  or  light,  they 
were  chained  in  places  in  which  wild  animals  would  not 
be  kept.  Although  the  Ministry,  in  1819,  forbade  the  use 
of  underground  cells  and  required  rooms  with  windows, 
the  condition  was  not  much  improved  until  the  law  of 
1838  was  passed. 

In  Germany,  in  1817,  Hayner  issued  a  pamphlet  which 
exercised  great  influence.  His  description  of  the  abuses 
then  existing  is  pathetic.  He  especially  opposed  the  use 
of  chains  and  of  restraining-chairs,  which  impeded  motion 
and  often  led  to  crippling  of  the  limbs.  He  also  opposed 
the  view,  which  was  supported  by  physicans,  that  corporal 
chastisement  is  useful  in  the  treatment  of  the  insane.  He 
regarded  the  camisole  as  indispensable  at  times,  but  only 
for  a  few  hours,  during  which  time  a  nurse  must  be  in 
constant  attendance  on  the  patient.  This  requirement 
will  also  be  accepted  by  the  most  fanatic  opponent  of  re- 
straint. 

In  1796  Tuke  erected  in  York,  England,  an  asylum  for 
the  abolition  of  unnecessary  and  cruel  restraint,  and  this 
served  at  the  time  as  an  example  of  humane  treatment. 
But  no  one  dared  to  remove  mechanical  restraint  entirely, 


176  HANDBOOK    OF    INSANITY. 

and  half  a  century  elapsed  before  all  abuses  were  corrected,, 
especially  in  some  private  institutions.  In  1815  patients 
were  found  in  a  public  asylum  with  an  arm  or  leg  or  with 
both  limbs  chained  to  the  wall ;  the  chain  merely  allowed 
the  patients  to  stand  or  sit  upon  a  bench  fastened  to  the  wall. 
One  unfortunate  had  an  iron  ring  around  his  neck,  fas- 
tened by  a  chain,  ending  in  another  ring ;  the  latter  could 
slide  along  a  vertical  iron  rod,  six  feet  in  length,  which 
was  fastened  to  the  wall.  Around  his  body  was  placed  a 
strong  iron  band,  about  two  inches  wide,  which  had,  at 
each  side,  a  round  projection  to  enclose  the  arms  and  keep 
them  firmly  applied  to  the  body.  In  this  torture  the  pa- 
tient had  lived  twelve  years.  He  was  only  excited  peri- 
odically, and  during  long  intervals  was  comparatively 
conscious.  Finally  he  was  rescued  by  an  official  investi- 
gation. 

Under  such  circumstances  it  is  not  surprising  that  the 
demands  for  the  entire  abolition  of  restraint  became  louder 
and  louder.  The  no-restraint  system  required  the  in- 
troduction of  other  and  humane  methods  of  treatment, 
and  redounded  to  the  honor  of  its  founder,  Conolly. 
Wherever  the  old  system  was  supplanted  the  difference 
in  the  results  obtained  became  especially  noticeable. 
Imagine,  for  example,  the  effects  of  restraint  in  partially 
paralyzed  patients.  They  were  tied  down  in  large  night- 
chairs,  because  otherwise  they  would  soil  themselves. 
Here  they  sat  the  whole  day,  and  at  night  were  placed, 
bound,  upon  straw.  If  they  complained  or  shouted,  they 
were  quieted  by  blows.  If  we  contrast  this  with  the  care 
now  devoted  to  a  paralyzed  general  paretic  the  advantages 
of  the  new  system  are  seen  to  be  considerable.  Instead 
of  restraint  we  employ  baths,  and  soft  bedding  with  fre- 
quent changes. 

But  the  greatest  advantages  of  the  no-restraint  treat- 
ment were  shown  in  conscious  patients.  A  friendly  man- 
ner and  quiet  speech  aroused  confidence  where  formerly 
only  fear  and  distrust  prevailed.  The  patients  willingly 
obeyed  the  orders   of  kind   attendants.     It  has   become 


INTRODUCTION   OF   NON-RESTRAINT.  177 

more  and  more  evident  that  well-trained  and  kind  attend- 
ants are  absolutely  necessary  to  the  proper  treatment  of 
the  insane. 

As  a  matter  of  course  there  were  great  difficulties  con- 
nected with  the  introduction  of  the  no-restraint  system, 
but  it  was  soon  found  that  noise  and  disorder  rapidly 
diminished,  and  that  periods  of  excitement  ran  a  more  rapid 
course.  The  removal  of  measures  of  restraint  was  found 
most  useful  in  suicidal  cases.  The  destruction  of  win- 
dows, bedding,  and  clothing  became  less  frequent,  because 
the  attendants  were  more  careful  and  attentive.  Tempo- 
rary isolation,  however,  was  found  necessary,  usually 
without  any  notable  resistance  on  the  part  of  the  patients, 
who  felt  that  solitude  was  good  for  them. 

The  physicians  themselves  were  compelled  to  have  pa- 
tience. But  they  found  that  scenes  which,  at  first  sight, 
appeared  full  of  confusion  and  excitement  generally  re- 
solved themselves  into  simple  conditions  if  quietly  treated 
for  a  few  minutes.  Violent  conduct  and  threatening 
speech  soon  ceased  if  not  opposed  by  irritability  and 
displeasure.  Patient,  quiet  admonition  and  evidence  of 
self-control  rarely  failed  to  produce  their  effects.  The 
same  spirit  of  humanity  extended  to  the  attendants  and 
patients.  Thus  the  new  system  rapidly  gained  adherents. 
It  was  developed  in  detail  and  found  new  auxiliary  meas- 
ures in  the  different  modes  of  occupation  of  patients. 
Every  year  brought  new  proofs  of  the  utility  of  such  princi- 
ples in  curable  and  incurable  cases,  and,  what  was  most  ef- 
fective, the  number  of  recoveries  increased.  Even  in  the 
first  few  years  Conolly  employed  education  as  a  means  of 
cheering  and  quieting  the  patients  in  his  asylum.  Not 
alone  did  the  uneducated  enjoy  the  acquisition  of  new 
knowledge,  but  the  recalling  of  former  knowledge  was  a 
source  of  pleasure  to  the  cultured  and  facilitated  their 
recovery. 

The  possibility  of  dispensing  entirely  with  restraint  has 
been  often  demonstrated,  but  on  the  whole  the  carrying 
out  of  the  no-restraint  system  has  become  largely  a  ques- 
12 


178  HANDBOOK   OF   INSANITY. 

tion  of  expense.  The  few  exceptions  only  prove  the  rule. 
In  order  to  prevent  abuse,  however,  we  must  hold  fast  to 
the  rule  that  restraint  is  inadmissible  in  incurable  cases, 
especially  when  constant  medical  supervision  is  wanting. 
It  must  be  confessed,  however,  that  while  the  changes 
mentioned  were  adopted  in  English  asylums,  the  treat- 
ment of  the  insane  without  measures  of  restraint  did  not 
at  first  meet  with  a  favorable  reception  on  the  continent 
of  Europe.  But  finally  the  results  of  no-restraint  became 
so  firmly  established  that  the  victory  is  now  decided. 

D.    PRESENT  TREATMENT  OF  THE  INSANE. 

The  question  whether  curable  insane  should  be  separated 
from  incurable  cases  has  long  been  debated.  As  a  matter 
of  course,  the  mingling  of  recent  cases  with  idiots,  epilep- 
tics and  filthy  patients  must  exercise  an  injurious  influence 
upon  the  former.  The  necessary  differences  in  the  ar- 
rangements for  treating  both  classes  of  patients  also  led 
to  the  desire  for  separate  asylums.  In  Germany  institu- 
tions were  accordingly  erected  for  curative  purposes  alone, 
and  in  these  the  attempts  at  reform,  which  were  neces- 
sarily attended  with  considerable  expense,  could  be  carried 
out  more  readily,  while  the  old  asylums  were  furnished 
with  suitable  changes  for  incurable  cases.  The  compara- 
tively frequent  recoveries  in  the  former  class  rapidly 
removed  some  of  the  former  prejudices  of  the  public.  The 
increased  cost  of  such  asylums  located  in  different  places 
led  to  the  erection  of  two  independent  asylums  in  the  same 
place.  Any  errors  in  prognosis  as  regards  curability  or  in- 
curability could  then  be  corrected  very  easily,  and  the  pa- 
tients could  be  transferred  from  one  division  to  the  other. 
In  this  way  complete  separation  became  impossible.  It  was 
found,  however,  that  the  partial  mingling  of  both  classes 
of  cases  was  not  so  injurious  as  had  been  supposed,  if  care 
were  taken  to  separate  the  excited  and  filthy  patients  from 
the  quiet  ones.  The  presence  of  some  incurable  patients 
was  even  found  to  be  beneficial,  in  a  measure,  because  it 
helped  newly  admitted  patients  in  becoming  accustomed 


MODERN   INSANE   ASYLUMS.  179 

to  the  new  order  of  things.  Moreover,  some  of  the  old 
patients  received  a  fresh  stimulus  from  the  recent  cases 
which  had  just  come  from  the  bustle  of  the  outside  world, 
the  discharge  of  cured  patients  permitted  them  to  gain 
fresh  hope,  and  thus  became  an  incitement  to  renewed  ac- 
tivity, the  best  means  of  cure.  The  chief  element,  then,  is 
not  so  much  the  complete  separation  of  curable  and  incur- 
able cases,  as  it  is  the  most  humane  treatment  under  the 
different  external  conditions. 

Every  insane  asylum  now  possesses  a  medical  superin- 
tendent and  all  the  means  for  treating  the  sick.  In  addi- 
tion the  entire  building  should  create  an  impression  of 
comfort.  Whenever  possible  the  asylum  should  be  placed 
not  alone  in  a  healthy  district,  but  also  in  one  which  is 
full  of  natural  beauties.  It  should  be  surrounded  by  large 
gardens,  and  when  mechanical  means  of  isolation  are 
necessary  this  should  be  done,  not  by  heavy  bars  of  iron 
but  by  light  railings  or  thick  unbreakable  glass.  The 
rooms  should  be  enlivened  by  comfortable  furniture  and 
pictures  on  the  walls ;  pianos,  billiard  tables,  and  reading 
rooms  serve  for  the  entertainment  of  the  patients.  Occu- 
pation is  made  possible  in  numerous  work-rooms,  and  in 
attending  to  garden  work. 

The  more  free  the  treatment  became,  the  more  evident 
it  became  that  very  many  patients  were  capable  and  desir- 
ous of  work.  The  former  anxious  seclusion  from  the  outer 
world  was  found  to  be  unnecessary,  and  the  constantly  in- 
creasing overcrowding  led  to  the  development  of  free  meth- 
ods of  caring  for  the  insane.  The  most  extensive  develop- 
ment was  found  in  the  farming  colonies  for  males,  associ- 
ated with  large  institutions.  These  colonies  are  small 
farms,  which  are  tended,  in  great  part,  by  the  patients 
themselves.  Not  alone  does  this  afford  a  useful  activity 
to  the  patients,  but  it  also  diminishes  the  cost  of  their 
maintenance. 

Less  extensive  is  the  so-called  family  care,  in  which  one 
or  more  patients  are  cared  for  in  the  family  of  a  stranger. 
This  is  also  known  as  a  scattered  colonial  system.     More 


180  HANDBOOK    OP    INSANITY. 

or  less  close  connection  with  a  neighboring  asylum  affords 
the  possibility  of  using  baths,  and  permits  a  return  to  the 
asylum  whenever  this  becomes  necessary.  When  such 
an  arrangement  is  possible,  the  patients  feel  themselves 
very  fortunate ;  they  consider  themselves  useful  members 
of  human  society,  and  notice  that  their  morbid  tendencies 
and  ideas  are  recognized  and  treated  as  such.  As  a  mat- 
ter of  course,  it  is  assumed  that  such  families  are  subject 
to  regular  supervision.  The  results  are  uniformly  good, 
and  the  system  merits  further  extension  in  Germany.  It 
has  been  extensively  carried  out  in  Scotland  and,  for  sev- 
eral centuries,  in  Gheel,  Belgium. 


SPECIAL   PART. 


CLASSIFICATION    OF    INSANITY. 

The  classification  of  insanity  is  the  most  difficult  prob- 
lem in  scientific  psychiatry.  None  has  hitherto  proven 
satisfactory,  and  my  own  classification  undoubtedly  pos- 
sesses many  defects.  It  merely  attempts  to  furnish  a 
rapid  survey  of  the  essentially  different  clinical  forms  of 
insanity. 

Three  plans  of  classification  have  been  hitherto  adopted, 
viz.,  upon  an  anatomo-pathological  basis,  and  upon  the 
basis  of  the  causes  or  the  symptoms  of  insanity.  All 
these  systems  have  been  artificial.  Anatomical  changes 
are  absent  in  the  majority  of  cases ;  so  many  causes  act 
at  the  same  time  that  it  would  often  be  arbitrary  to  regard 
one  as  decisive  in  the  individual  case;  even  the  symptoms 
of  insanity  are  sometimes  so  manifold  that  accidental  mat- 
ters may  long  conceal  the  essential  elements. 

But  so  long  as  we  are  not  even  able  to  explain  the  men- 
tal processes  in  the  healthy  nervous  system,  the  attempt 
to  circumscribe  its  abnormalities  within  a  natural  system 
will  be  unsuccessful.  Nothing  remains  but  a  classifica- 
tion with  the  aid  of  the  different  artificial  systems. 

The  relationships  between  different  groups  of  insanity 
also  appear  in  our  classification  and  characterize  their 
clinical  course.  But  the  artificial  character  of  the  entire 
system  is  shown,  for  example,  by  the  fact  that  the  curable 
forms  of  insanity  are  not  only  found  among  the  simple, 
usually  curable  mental  disorders,  but  that,  like  the  forms 
occurring  after  intoxications  and  some  forms  occurring 
during  fever,  they  must  also  be  placed  alongside  the  incu- 
rable forms  of  dementia.  On  the  other  hand,  paranoia, 
despite  its  simple  functional  nature,  is  characterized,  as  a 

183 


184  HANDBOOK    OF    INSANITY. 

rule,  by  a  more  unfavorable  course,  and  yet  must  be  placed 
alongside  the  other  simple  mental  disorders. 

Even  the  oldest  observers  made  a  fundamental  distinc- 
tion which  is  still  maintained ;  it  depends  upon  the  pre- 
dominance of  a  depressed  or  an  excited  mood.  These  moods 
may  occur  in  all  forms  of  mental  disorders,  either  singly 
or  alternating  with  one  another.  Hence,  the  first  classifi- 
cation, which  runs  through  all  the  individual  forms  of 
insanity,  is  that  into  depressed  and  exalted  conditions, 
dependent  mainly  on  disorders  of  emotional  life,  but  al- 
ways accompanied  by  disorders  in  the  association  of 
ideas;  disturbance  of  consciousness  may  also  be  present 
in  varying  degrees. 

Although  we  everywhere  find  conditions  of  depression 
and  exaltation,  yet  certain  groups  of  symptoms  are  known 
under  the  terms  melancholia  and  mania.  A  disturbance 
of  the  association  of  concepts  is  also  demonstrable  in  almost 
all  cases;  but  in  only  a  few  clinically  distinct  groups  do 
we  apply  the  term  paranoia,  which  includes  the  terms 
"  verruecktheit "  and  "wahnsinn"  and  the  secondary  con- 
fusion. A  few  subdivisions  readily  result  from  the  com- 
bination of  disorders  in  the  connection  and  course  of  the 
concepts  with  disorders  of  consciousness,  especially  of  the 
perceptive  processes. 

The  separation  of  so-called  hallucinatory  psychoses  has 
been  attempted  anatomically  as  well  as  clinically,  but  is  not 
yet  practicable.  For  the  present  it  seems  better  not  to 
regard  hallucinations  as  independent  diseases,  but  merely 
to  examine  their  relations  to  the  clinical  history  of  the 
psychosis. 

The  symptom-groups  of  melancholia  and  mania  and 
their  periodical  alternation,  and  paranoia  form  one  main 
group  of  simple  mental  disorders,  which  is  distinguished 
from  the  group  associated  with  permanent  anatomical  or 
general  diseases.  The  simple  mental  disorders  are  gen- 
erally to  be  regarded  as  probably  curable;  the  affections 
belonging  to  the  second  group  are,  in  great  part,  incurable. 
The  simple  or  functional  disorders  may  also  be  attended 


CLASSIFICATION.  185 

with  more  profound  anatomical  changes  and  pass  into  the 
more  unfavorable  forms.  Hence  our  classification  can 
only  be  regarded  as  a  temporary  makeshift.  This  is  shown 
most  clearly  in  the  position  of  dementia  in  our  system, 
which  forces  us  to  place  the  simple  disorders  that  terminate 
in  imbecility  and  dementia  in  a  special  sub-group  of  the 
second  main  division  because  its  occurrence  is  attended 
very  often  by  distinct  anatomical  changes  in  the  brain. 
Primary  dementia  is  also  placed  improperly  in  the  same 
group,  in  order  that  the  similar  clinical  histories  should 
not  be  separated.  Still  more  forced  is  the  position  of  con- 
genital feeble-mindedness,  so-called  imbecility,  in  the  same 
group,  because,  although  anatomical  changes  in  the  struc- 
ture of  the  brain  are  undoubtedly  present,  they  are  not  yet 
accessible  to  our  gross  methods  of  examination.  The  dis- 
cussion of  imbecility  cannot  be  separated,  however,  from 
that  of  idiocy  and  other  forms  of  feeble-mindedness. 

The  second  main  group  also  contains  the  practically 
important  forms  of  dementia  with  paralyses,  especially 
dementia  paralytica  proper,  then  the  psychoses  associated 
with  epilepsy  and  other  general  neuroses,  among  which 
the  nervous  exhausted  conditions  of  recent  times  constantly 
occupy  more  and  more  space.  The  addition  of  alcoholic 
forms,  although  apparently  at  variance  with  an  artificial 
system,  is  permissible  because  they  serve  to  indicate  that 
we  have  to  consider,  in  mental  disorders,  not  alone  psy- 
chological or  anatomical  causes  in  the  central  nervous 
system,  but  also  chemical  changes  in  the  entire  body,  as  a 
matter  of  course  including  the  central  nervous  system. 


II. 

SIMPLE  MENTAL  DISORDERS. 
A.    MELANCHOLIA. 

The  chief  characteristic  of  melancholia  is  a  sorrowful 
mood  of  varying  intensity,  more  or  less  associated  with 
disorders  of  consciousness,  and  of  the  association  of  ideas. 
All  of  these  together,  but  chiefly  the  disorders  of  emotional 
life,  give  rise  to  the  morbid  manifestations  of  the  volition 
and  acts  of  the  patient.  In  the  simplest  form  of  inde- 
pendent melancholia  the  depressive  affects  and  feelings  or 
the  anxious  mood  occupy  the  foreground.  There  is  a  grad- 
ual transition  between  conditions  of  dissatisfaction  and 
bad  temper  without  sufficient  provocation,  and  this  simple 
melancholia.  If  such  feelings  permanently  dominate  the 
mood,  then  further  disorders  of  the  mental  processes  fol- 
low. The  patient  notices  that  his  ideas  run  a  slower 
course,  that  alongside  the  painful  contents  of  his  con- 
sciousness there  is  no  room  for  other  thoughts.  At  first 
he  feels  with  pain  a  growing  indifference  to  those  around 
him,  but  gradually  this  is  lost  and  the  painful  feelings 
suppress  all  other  concepts  or  give  to  them  the  same  pain- 
ful color.  Not  alone  has  the  former  enjoyment  of  society 
and  intellectual  pleasures  disappeared,  but  the  satisfaction 
in  his  own  occupation  disappears  in  a  striking  manner. 
From  these  beginnings  develop  the  different  forms  of 
melancholia. 

At  first  there  is  often  a  distinct  feeling  of  being  sick, 
the  patient  sometimes  endeavors  to  conceal  the  change  in 
his  tendencies  and  feelings.  The  unnatural  character  of 
his  sensations  and  his  distaste  for  things  formerly  held 
in  high  esteem,  often  lead  him  to  complain  that  he  can  no 

186 


PRODROMES.  187 

longer  enjoy  anything.  He  feels  himself  torn  out  of  his 
former  community  with  men,  he  is  filled  with  mistrust 
and  suspicion,  and  thus  resists  all  external  impressions. 
A  sensation  of  changed  individuality  constantly  oppresses 
him.  Although  he  still  acknowledges  that  some  of  his 
anxious  notions  are  false,  yet  it  is  impossible  for  him  to 
feel,  think,  or  act  differently.  The  loss  of  self-reliance 
becomes  more  and  more  distinct,  accompanied  by  true 
spiritual  pain.  He  seeks  solitude,  becomes  silent  or  merely 
states  that  everything  around  him  has  changed.  Rela- 
tives and  friends  appear  to  act  differently,  he  does  not 
deserve  their  care,  he  is  too  wicked.  The  world  has  be- 
come dead  to  him.  The  things  occurring  around  him, 
even  his  own  experiences,  are  felt  by  the  patient  as  by  an 
outsider.  Every  attempt  to  influence  him  leads  to  a  pain- 
ful disturbance  of  his  concepts.  Very  irritable  individ- 
uals, especially  women,  soon  acquire  obscure  notions  that 
injury  is  to  be  inflicted  upon  them,  or  every  cheerful  re- 
mark increases  the  sorrowful  depression  into  apathetic 
brooding  or  impulsive  acts,  which  are  intended  to  relieve 
the  distressed  ego  of  the  patient. 

The  contents  of  consciousness  are  not  always  confined 
to  these  anxious  concepts;  a  well-preserved  memory 
furnishes  new  food  for  self-torturing  thoughts.  These 
thoughts  run  a  slower  course  and  are  associated  solely 
with  the  fundamental  mood ;  the  external  perceptive  pro- 
cesses are  delayed.  Voluntary  attention  is  hardly  possible 
or  is  very  fleeting. 

With  the  further  development  of  the  disease  certain 
ideas  appear  unsought  out  of  the  general  feeling  of  de- 
pression and  present  themselves  to  the  patient  as  an  expla- 
nation of  his  sufferings.  No  conscious  logical  selection 
permits  the  development  of  these  explanations,  but  the 
entire  previous  contents  of  consciousness  are  again  lived 
through,  and  any  part  thereof  may  come  in  contact  with 
the  present  feeling.  It  is  surely  no  accident  that,  in  very 
many  cases,  this  connection  is  afforded  by  religious  ideas, 
because  these  adhere  firmly  to  the  mind  in  earliest  youth.. 


188  HANDBOOK   OF   INSANITY. 

In  a  feeling  of  despair  the  patient  seeks  refuge  in  religion, 
but  he  can  no  longer  pray,  and  doubts  concerning  the 
firmness  of  his  own  belief  increase  his  notion  of  wicked- 
ness to  a  morbid  height.  The  Bible  is  read,  but  no  com- 
fort is  found ;  only  texts  which  he  refers  to  himself.  Great 
influence  is  exerted  by  those  writers  who  discuss  the  un- 
pardonable sin  against  the  Holy  Ghost.  Its  very  obscurity 
is  dangerous  to  the  melancholic  patient,  because  he  is  apt 
to  find,  in  his  own  life,  some  circumstance  which  may  be 
interpreted  as  such  a  sin.  Sexual  aberrations  are  espe- 
cially apt  to  enter  this  circle  of  thought.  Other  self-accu- 
sations concerning  sins  that  have  been  committed  are  also 
frequent,  but  they  usually  remain  general  in  character. 
The  patient  fears  that  he  has  forfeited  salvation,  and 
that  he  is  doomed  to  eternal  damnation. 

Others  believe  that  they  are  victims  of  human  justice, 
they  dread  the  prison  and  capital  punishment.  A  patient 
suffers  terror  of  soul,  like  a  criminal  after  a  heinous  crime. 
These  general  reproaches  are  usually  gradually,  but  some- 
times immediately,  converted  into  a  special  notion  which 
is  the  starting-point  of  new  melancholic  complaints.  This 
change  is  a  serious  one,  and  proves,  at  least,  that  recovery 
will  not  occur  rapidly.  It  may  also  arouse  doubts  con- 
cerning the  diagnosis,  inasmuch  as  the  delusion  of  perse- 
cution, of  "  verruecktheit, "  has  much  similarity  with  these 
conditions.  A  knowledge  of  the  course  of  the  disease 
alone  will  prevent  a  mistake.  The  chief  feature  is  the 
affect  of  melancholia.  Moreover,  ideas  of  self-aggrandize- 
ment are  hardly  ever  wanting  in  "verruecktheit,"  while 
the  melancholic  usually  has  lessened  notions  of  his  own 
worth. 

The  clinical  history  changes  when  hallucinations  de- 
velop. They  usually  bear  the  impress  of  the  depressed 
mood,  and  their  sensory  distinctness  removes  every  doubt 
which  may  have  existed.  Voices  threaten  death  and 
damnation.  The  sound  of  shooting  or  of  bells  is  connected 
with  the  idea  of  execution.  Shapes  and  shadows  frighten 
and  threaten.      The  patient  sees  himself  surrounded  by 


PRECORDIAL    FEAR.  189 

flames  or  hell,  and  abysses  open  before  his  feet.  He  smells 
corpses  and  tastes  poison  in  his  food.  The  clouded  con- 
sciousness mistakes  harmless  words  and  sounds  for  dan- 
gerous influences.  A  dull  pain  in  the  head  becomes  a 
proof  of  profound  disease  of  the  brain  and  impending 
death.  The  terror-filled  fancy  finds  in  all  perceptions  a 
confirmation  of  its  fears.  The  sympathy  of  relatives 
seems  like  an  attempt  to  conceal  a  new  misfortune  or 
danger. 

These  different  symptoms  appear  in  varying  degrees 
and  combinations,  so  that  the  manifestations  of  simple 
melancholia  may  be  very  manifold.  A  materially  differ- 
ent picture  is  presented  when  the  feeling  of  fear  enters 
the  symptom-group.  This  feeling  is  referred  to  the 
cardiac  region  (precordial  fear),  and  is  one  of  the 
most  important  and  frequent  accompaniments  of  severe 
melancholia.  The  external  quiet  of  simple  melancholia 
becomes  converted  into  anxious  restlessness.  From  the 
start  sleep  is  almost  always  disturbed  because  the  patient 
is  tormented  by  the  pressure  in  the  cardiac  region ;  other 
disagreeable  sensations  soon  follow,  such  as  constriction 
of  the  neck  or  a  dull  feeling  in  the  head ;  bad  dreams  and 
anxious  thoughts  become  more  numerous.  The  daily  work 
may  make  the  condition  endurable  during  the  day  for  a 
time,  but  in  the  stillness  of  night  it  is  rapidly  intensified, 
and  if  sleep  does  not  refresh  the  excited  brain,  the  days, 
likewise  are  filled  more  and  more  with  disheartening  fears. 

The  implication  of  the  organs  of  the  body  is  much  more 
distinct  in  anxious  than  in  simple  melancholia.  The  ap- 
petite is  lost,  the  nutrition  is  rapidly  impaired.  Respiration 
is  superficial,  the  heart's  action  is  accelerated  and  often 
irregular,  the  pulse  is  small,  the  skin  cool.  When  the 
terror  shows  variations  or  occurs  in  paroxysms,  its  increase 
is  shown  by  suppression  of  the  urine  and  perspiration,  its 
subsidence  by  increase  in  these  secretions.  The  more 
chronic  the  precordial  fear  the  more  indistinct  do  these 
symptoms  become. 

General  restlessness  soon  makes  its  appearance.     The; 


190  HANDBOOK   OF   INSANITY. 

patient  can  no  longer  remain  in  one  place ;  he  runs  about 
the  room,  sits  down,  rises,  goes  out  of  doors,  always  with 
the  indefinite,  but  unfulfilled  hope  that  the  change  may 
relieve  the  terrible  restlessness. 

Although  confined  to  a  few  anxious  concepts,  the  flight 
of  ideas  may  be  accelerated.  Delusions  may  now  develop, 
intensified  by  hallucinations.  Religious  notions  are  often 
awakened,  and  are  then  explained  as  the  dread  of  being 
possessed  by  evil  spirits.  With  the  increasing  terror  the 
consciousness  is  gradually  impaired.  Perception  of  the 
outer  world  takes  place  only  with  reference  to  the  domi- 
nant affect. 

The  affect  is  shown  more  and  more  distinctly  in  the 
facial  expression.  The  facial  muscles  become  rigid  and 
unchangeable  folds  appear;  the  brow  is  furrowed,  the 
angles  of  the  mouth  drawn  downward,  the  mouth  often 
appears  wider,  almost  quadrangular,  the  lips  are  gently 
moved  to  and  fro.  In  the  higher  grades  anxious  moaning 
and  sighing  accompany  the  unchanging  complaints  and 
exclamations.  One  pleads  for  mercy,  the  begs  other  that  he 
may  be  spared  or  perhaps  that  he  be  burned  to  death,  de- 
spite his  fear  of  this  agonizing  fate.  The  contradiction 
is  perhaps  only  apparent  because  the  terror  is  so  dreadful 
that  even  burning  to  death  appears  the  lesser  evil.  This 
condition  may  last  weeks  and  months.  The  patient  clings 
to  every  one  around  him  and  force  is  often  required  to 
remove  him.  Then  the  unfortunate  wrings  his  hands, 
beats  his  head,  tears  the  skin  of  his  face  and  hands,  tears 
his  hair,  and  is  constantly  inflicting  slight  wounds.  The 
restlessness  may  increase  still  further  to  inarticulate 
shouting,  unceasing  running  about ;  the  patient  cannot  be 
dressed  or  undressed  without  force.  It  is  only  during  a 
temporary  subsidence  of  the  terror  that  we  occasionally 
hear  expressions  which  permit  us  to  recognize  that  the 
despair  is  associated  with  the  former  psychical  processes. 
Soon  the  terror  again  conceals  these  processes,  and  only 
the  later  reports  after  recovery  prove  their  continuance. 

Now  come  the  impulsive  manifestations  of  the  tortured 


RAPTUS   MELANCHOLICTJS.  191 

ego  and  acts  of  violence,  which  must  be  regarded  as  dis- 
charges of  the  terror-laden  consciousness.  Suddenly  the 
patient  destroys  everything  within  his  reach.  Not  infre- 
quently he  mutilates  his  own  body;  tears  out  his  eyes, 
cuts  off  the  genitalia,  etc.  Sometimes  a  leap  into  the  river 
or  out  of  the  window  closes  the  dreadful  scene.  Such  acts 
are  sometimes  due  merely  to  the  endeavor  to  relieve  the 
condition  of  internal  tension.  We  then  find  impulsive 
actions,  which  are  inexplicable  even  to  the  patient  after 
recovery  has  taken  place.  This  one  kills  his  parents  or 
children,  another  kills  his  wife.  The  sight  of  a  knife 
makes  the  thought  and  deed  one.  This  so-called  raptus 
melancholicus  is  perhaps  not  so  dangerous  in  anxiously 
excited  patients  because,  as  a  rule,  they  are  sent  early  to 
an  asylum.  But  these  sudden  discharges  may  also  occur 
in  patients  who  were  apparently  quiet.  Especially  dan- 
gerous in  this  respect  is  melancholia  in  which,  for  a  long 
time  prior  to  the  act  of  violence,  the  patient  may  have  re- 
mained motionless  or  even  rigid. 

Attacks  upon  surrounding  individuals,  self -mutilations, 
and  attempts  at  suicide  serve  the  involuntary  purpose  of 
freeing  the  patient  from  his  intolerable  position.  In  fact, 
after  such  acts  they  feel  relieved,  as  a  rule,  and  this  may 
even  be  followed  by  recovery.  The  profound  disturbance 
of  consciousness  at  the  time  permits  only  an  indistinct 
remembrance  of  the  deed,  so  that  remorse  is  not  increased 
by  memory.  Moreover,  he  is  often  apt  to  regard  himself 
as  the  unresisting  tool  of  a  higher  power. 

The  attacks  of  precordial  fear  usually  develop  suddenly ; 
more  rarely  they  are  preceded  by  oppression,  headache, 
and  vertigo.  They  may  be  repeated  at  short  intervals  or 
after  the  lapse  of  years.  In  the  intervals  the  depression 
may  be  distinct  or  it  may  be  so  slight  that  the  patient  ap- 
pears healthy  amid  the  accustomed  surroundings.  As  a 
rule,  the  more  violent  the  attack  the  more  permanent  is 
the  subsequent  quiet,  but  there  are  also  cases  in  which 
the  act  of  violence  precedes  the  following  sj-mptoms. 

A  disease  which  began  as  simple  melancholia  may  lead 


192  HANDBOOK   OF  INSANITY. 

to  a  materially  different  symptomatology.  Slowly  or  rap- 
idly there  develops  a  rigid  absorption  in  the  internal  men- 
tal processes  (stupor).  The  disorder  of  consciousness  is 
not  so  profound  as  it  appears,  as  is  shown  by  the  fleeting 
mimic  movements,  wrinkling  of  the  forehead,  twitching 
of  the  lids,  an  anxious  gaze.  A  sudden  change  of  color 
or  a  deep  sigh  shows  that  the  motionless  patient  is  filled 
with  anxious  thoughts,  and  convalescent  patients  confirm 
this  opinion.  In  more  severe  cases  the  internal  life  of 
such  patients  becomes  a  real  dreamy  condition,  in  which 
external  impressions  are  received  in  a  confused,  shadowy, 
and  inimical  manner.  A  terrible,  baseless,  but  paralyz- 
ing fear  takes  possession  of  consciousness  and  makes  every 
movement  impossible,  while  at  the  same  time  the  fright- 
ful consciousness  of  inability  to  act  or  to  will  increases  the 
terror  tenfold.  These  patients  sit  as  rigid  as  a  statue, 
with  an  anxiously  astounded  or  rigid,  mask-like  expres- 
sion. But  they  do  not  always  neglect  the  care  of  their 
immediate  bodily  necessities.  It  is  only  in  the  most  severe 
grades  that  they  are  unable  to  dress  themselves,  keep 
themselves  clean,  and  take  food  alone..  These  acts  are 
continued  for  a  long  time,  although  slowly,  and  show  that 
the  patient  at  least  perceives  the  internal  processes  of  his 
own  body.  Sleep  is  usually  disturbed  very  much  and  often 
there  is  complete  insomnia,  although  the  patient  lies  qui- 
etly in  bed. 

In  these  conditions  the  concomitant  symptoms  of  mel- 
ancholia appear  more  distinctly.  The  speech  may  exhibit 
striking  changes.  In  simple  depression  it  is  slow,  infre- 
quent, and  monotonous:  the  voice  sounds  muffled,  while 
the  timbre  varies  according  to  the  degree  of  fear,  from  a 
gentle  tremulous  voice  to  shrill  outcries  and  violent  moans 
and  complaints.  In  anxious  excitement  the  speech  be- 
comes more  rapid  but  retains  a  peculiar  tremor. 

The  loss  of  sleep,  which  is  common  to  all  forms  of  mel- 
ancholia, is  often  followed  by  painful,  or  at  least  annoying, 
sensations  in  the  head,  such  as  pressure  at  the  vertex,  ten- 
sion of  the  occiput,  or  a  feeling  of  emptiness  which  is 


DIGESTIVE   DISORDERS.  193 

sometimes  translated  by  the  allegorical  expression  that  the 
brain  has  disappeared  or  that  the  soul  is  lost. 

Neuralgic  pains  are  rare ;  the  apparent  analgesia  in  con- 
ditions of  great  fear  and  impairment  of  consciousness  must 
be  attributed  to  the  lack  of  attention. 

Digestion  is  constantly  impaired  in  melancholia.  It  is 
possible  that  a  gastro-intestinal  catarrh  may  give  rise  to  a 
refusal  to  take  food  through  the  agency  of  a  secondary 
delusion,  but,  as  a  rule,  such  refusal  develops  independently 
out  of  psychical  motives.  Constipation  is  very  frequent, 
but  this  may  be  preceded,  more  often  it  is  followed,  by  dis- 
tinct evidences  of  gastro-intestinal  catarrh,  undoubtedly 
due  to  the  insufficient  secretion  of  digestive  fluids.  The 
clearest  evidence  of  the  imperfect  digestion  and  absorption 
of  food  is  the  rapid  diminution  in  the  weight  of  the  body 
at  the  beginning  of  melancholia.  After  the  severe  forms 
of  melancholia  have  lasted  for  some  time,  even  if  food  is 
not  refused,  general  emaciation  and  exhaustion  may  pro- 
ceed to  a  fatal  termination.  Even  forced  feeding  is  use- 
less when  the  exhausted  nervous  energy  is  powerless  to 
stimulate  digestion. 

Refusal  to  take  food  in  consequence  of  delusions  is  one 
of  the  gravest  symptoms  of  melancholia.  It  is  rarely  as- 
sociated with  the  intention  to  put  an  end  to  life  by  starva- 
tion, but  the  patients  complain  that  they  have  lost  their 
fortunes,  and  refuse  to  take  food  because  they  cannot  pay 
for  it  or  because  they  are  depriving  others  of  food. 

The  secretory  activity  of  various  organs  is  affected. 
Tears  do  not  flow,  perspiration  is  usually  suppressed,  the 
skin  is  dry,  the  hair  and  nails  become  dry  and  brittle. 
Apart  from  the  attacks  of  fear,  the  urine  is  small  in  quan- 
tity ;  thick,  tough  saliva  sometimes  flows  from  the  corners 
of  the  mouth. 

Menstruation  is  disturbed,  often  absent.  Sexual  desire 
is  usually  abolished,  but  obstinate  masturbation  is  some- 
times observed  in  profound  impairment  of  consciousness. 

Respiration,  whether  slow  or  accelerated,  is  always  su- 
perficial. There  is  often  general  anaemia  from  the  start, 
13 


194  HANDBOOK   OF   INSANITY. 

and  this  increases  with  the  further  course  of  the  disease. 
The  diminished  activity  of  the  heart  is  soon  shown  in 
various  ways.  The  face,  hands,  and  feet  are  slightly 
swollen,  and  these  parts  soon  become  bluish  in  color,  like 
certain  of  the  mucous  membranes.  The  hands  and  feet 
are  apt  to  be  cold  to  the  feel,  while  the  internal  excitement 
is  manifested  in  the  face  by  heat  and  sweating  of  the  fore- 
head. The  pulse  is  generally  small  and  tense,  but  it 
changes  with  the  variations  in  the  primary  affect. 

One  striking  symptom  is  observed  in  all  forms  of  insan- 
ity, but  is  especially  frequent  in  melancholia,  viz. ,  a  sud- 
den change  of  mood.  In  the  midst  of  the  depression  a 
temporary  cheerfulness  suddenly  appears,  more  frequently 
during  the  development  and  subsidence  of  the  disease  than 
at  its  height.  With  the  return  of  the  depression  the 
cheerfulness  is  often  converted  into  self-reproaches  and 
proofs  of  the  patient's  own  perversity  and  wickedness. 

Melancholia  usually  runs  a  very  slow  course,  lasting  at 
least  months,  and  occasionally  years ;  in  very  rare  cases  it 
lasts  only  a  few  hours,  but  hallucinations  or  delusions  are 
then  necessary  for  diagnosis.  The  development  of  the  dis- 
ease sometimes  takes  place  by  fits  and  starts,  and  frequent 
changes  in  the  severity  of  the  symptoms  are  common  in 
all  stages.  These  may  be  due  to  sudden  changes  of 
temperature,  the  onset  of  the  menstrual  period,  even  the 
growing  darkness  of  twilight  aggravates  the  symptoms  in 
some  cases. 

Moderate  grades  of  melancholia  with  periods  of  notable 
improvement  may  last  many  years.  Such  patients  can 
usually  maintain  their  position  in  their  accustomed  sur- 
roundings. After  a  time  the  family  attaches  little  weight 
to  their  complaints,  and  to  the  occasional  threat  of  suicide. 
Even  in  this  apparently  slight  degree  of  development  of 
the  disease  there  is  great  danger  of  suicide.  A  suddenly 
developing  precordial  fear  compels  a  discharge  through 
the  medium  of  an  act  of  violence,  and  the  danger  of  sui- 
cide should  not  be  forgotten,  at  least  by  the  physician. 

Every  melancholia  may  become   chronic.      The  more 


CONVALESCENCE.  195 

violent  sypmtoms  often  subside ;  the  hallucinations  become 
less  vivid,  the  delusions  fall  into  the  background,  the  ex- 
ternal restlessness  is  lost ;  the  patient  may  even  resume  an 
occupation  in  which  no  responsibility  is  incurred.  This 
condition  may  last  for  years,  especially  in  an  asylum, 
without  passing  into  recovery. 

In  other  cases  of  chronic  melancholia  the  symptoms  lose 
none  of  their  violence,  but  the  delusions  and  their  mani- 
festations assume  a  somewhat  stereotyped  character  and 
may  be  repeated  like  a  machine ;  the  rigid  or  anxious  ex- 
pression becomes  ingrained;  the  same  complaints  are 
repeated  in  the  same  way.  The  stupor  may  last  for  years 
until  death,  but  more  frequently  the  tension  is  somewhat; 
lessened ;  the  consciousness  becomes  clearer,  although  the 
patient  does  not  gain  a  clear  insight  into  his  disease.  He 
remains  apathetic  and  incapable  of  mental  effort,  and  the 
melancholia  may  continue  in  this  stage  until  the  end  of 
life.  He  has  no  sympathy  for  his  family,  and  the  sorrow- 
ful mood  is  still  dominant. 

The  transitions  into  recovery  will  now  occupy  our  at- 
tention. At  the  end  of  three  to  six  months  the  symptoms, 
as  a  general  thing,  gradually  subside  and  give  place  to  the 
normal  condition.  Sleep  first  imj)roves,  then  the  attacks 
of  fear  become  less  frequent  and  violent,  the  facial  expres- 
sion gains  life,  and  sympathy  for  the  family  begins  to  be 
manifested.  The  patients  begin  to  talk,  gain  appetite, 
and  show  more  and  more  of  their  former  individuality. 
Gradual  improvement  is  more  durable  than  sudden  im- 
provement, which  is  very  rare.  Certainty  of  recovery 
can  only  be  entertained  when  the  mental  improvement 
goes  hand  in  hand  with  physical  improvement.  As  a 
rule,  this  takes  place  very  rapidly.  On  the  other  hand,  a 
return  of  physical  improvement,  without  notable  mental 
recovery,  leads  us  to  fear  the  development  of  dementia. 
Another  important  point  is  the  self-knowledge  of  the  mor- 
bid character  of  the  affection,  which  generally  appears  with 
advancing  recovery. 

Although  gradual  improvement  is  the  usual  event,  yet 


196  HANDBOOK   OF   INSANITY. 

the  changing  symptoms  of  anxious  melancholia  and  the 
severe  phenomena  of  stupor  are  exposed  to  many  varia- 
tions during  the  period  of  convalescence,  although  they 
may  terminate  in  complete  recovery.  These  patients  some- 
times manifest  a  temporary  increase  of  the  feeling  of  well- 
being  before  complete  equilibrium  is  established.  On  the 
other  hand,  the  improvement  may  be  concealed  by  a  rigid 
demeanor,  until  finally  this  exhaustion  of  the  entire  ner- 
vous system  gives  place  to  complete  recovery. 

The  degree  of  insight,  after  recovery,  into  the  morbid 
character  of  the  disease  depends  materially  upon  the  de- 
gree of  culture  possessed  by  the  patient.  While  the  cul- 
tured individual  recognizes  the  melancholic  condition  as 
a  morbid  mental  state,  the  uncultured  patient  understands 
with  difficulty  that  he  has  suffered  from  a  disease  and 
speaks  of  dreams  and  fancies  that  tortured  him. 

Death  may  result,  with  comparative  rapidity,  after  vio- 
lent conditions  of  anxious  excitement,  as  a  result  of  the 
complete  exhaustion  and  insufficient  supply  of  food.  A 
series  of  dangerous  diseases  develop  with  comparative  fre- 
quency in  these  conditions,  for  example,  pneumonia,  and 
surgical  fever  following  wounds,  which  it  is  difficult  to 
treat  on  account  of  the  patient's  restlessness.  In  simple 
melancholia  and  stupor  pulmonary  tuberculosis  is  a  fre- 
quent complication. 

Finally,  the  termination  in  dementia  must  be  mentioned, 
although  it  is  not  frequent.  It  is  true  that  there  are  nu- 
merous protracted  cases  in  which  a  certain  grade  of  mental 
weakness  develops,  particularly  in  the  ethical  domain, 
but  the  intellectual  functions  are  usually  intact  for  a  long 
time  and  their  entire  loss  is  not  frequent.  The  best  meas- 
ure is  the  patient's  ability.  Although  independence  of  a 
high  grade  does  not  persist,  we  find  among  chronic  melan- 
cholies many  who,  under  proper  guidance,  are  able  to  do 
so  much  that  they  cannot  be  regarded  as  demented. 

In  general  the  prognosis  of  melancholy  may  be  regarded 
as  favorable.  Much  more  than  half  the  patients  recover, 
and  often  regain  a  certain  grade  of  mental  ability.     He- 


PROGNOSIS.  197 

reditary  taint  or  previous  injury  to  the  skull  with  cerebral 
concussion  are  unfavorable  factors.  If  the  exciting  causes, 
such  as  grief,  pecuniary  trouble,  nutritive  disorders  of  all 
kinds,  can  be  removed,  the  prospects  of  recovery  are  in- 
creased. The  age  of  the  patient  is  very  important. 
Childhood,  puberty,  and  old  age  are  more  endangered  than 
vigorous  youth  and  adult  life.  Melancholia  is  most  fre- 
quent at  the  period  of  sexual  development  and  hence  it  is 
especially  frequent  at  this  period  in  females,  in  whom  the 
sexual  life  affects  the  mental  processes  so  deeply.  The 
disease  is  not  much  less  frequent  in  old  age,  and  some 
observers  even  maintain  that  its  frequency  then  exceeds 
that  during  the  developmental  period.  The  period  of  in- 
volution of  the  body  brings  melancholia  to  an  especially 
distinct  expression.  The  women  are  again  attacked  more 
frequently  on  account  of  the  changes  induced  by  the  cli- 
macteric. There  are  still  other  causes  which  increase  the 
number  of  cases  in  females,  viz.,  pregnancy,  childbed,  and 
nursing.  The  latter  forms  do  not  differ,  as  regards  symp- 
toms, from  those  already  mentioned,  so  that  it  is  super- 
fluous to  speak  of  puerperal  melancholia  as  a  special  form 
of  disease. 

It  is  a  point  of  great  practical  importance  that  a  melan- 
cholia which  develops  in  a  brain  that  is  less  capable  of 
resistance  on  account  of  hereditary  or  acquired  taint,  differs 
in  some  respects  from  melancholia  developing  in  a  pre- 
viously healthy  brain.  In  the  former  event  there  is  often 
a  mixture  of  morbid  and  normal  elements.  This  may  de- 
ceive the  inexperienced  observer,  especially  as  the  patients 
have  a  tendency  to  justify  their  conduct  by  reasons,  to 
attribute  their  mood  to  sorrowful  circumstances.  The 
below-par  condition  of  the  brain  and  entire  nervous  con- 
stitution give  rise  to  the  course  of  this  form  of  melancholia 
which  is  also  called  constitutional.  It  would  be  better, 
however,  to  lay  stress  on  the  attempts  at  justification  and 
to  call  the  disease  a  folie  raisonnante  in  a  melancholic 
form.  These  cases  occur  chiefly  in  women.  Their  dis- 
satisfaction and  irritability  lay  them  open  to  the  danger 


198  HANDBOOK   OE'   INSANITY. 

of  being  misunderstood.  They  are  not  alone  morose  but 
incapable  of  work ;  they  are  especially  annoyed  by  repeated 
reproaches  and  are  then  regarded  as  quarrelsome  and  ma- 
licious on  account  of  the  changes  from  a  depressed  to  an 
angry  mood.  When  such  excitement,  which  has  been 
added  from  the  outside,  has  subsided,  the  patient  feels  so 
much  unhappier.  This  increase  of  the  painful  affect  ter- 
minates occasionally  in  suicide. 

The  chief  element  in  the  treatment  of  melancholia 
is  to  obtain  mental  and  physical  rest  for  the  patient. 
The  physician  must  make  the  family  recognize  at  the 
start  that  the  patient's  conduct  is  the  unavoidable  re- 
sult of  a  morbid  depression.  Distraction  by  means 
of  travel,  entertainments,  etc.,  is  to  be  avoided  by  all 
means,  and  inactivity  is  the  only  proper  treatment  at 
the  outset.  As  the  family  can  rarely  be  induced  to  follow 
such  advice,  independent  melancholias,  as  a  rule,  should 
be  transferred  to  an  asylum  as  early  as  possible.  This  is 
not  so  true  of  the  melancholic  conditions  with  which  other 
psychoses  begin.  If  the  patient  cannot  be  transferred, 
we  should  advise  the  family  to  be  as  unconcerned  and 
cheerful  as  possible,  neither  to  oppose  nor  to  accede  too 
much  to  the  patient's  complaints,  but  to  attach  the  chief 
importance  to  the  performance  of  the  numerous  little  acts 
which  fill  out  the  family  life.  A  quiet  pressure  of  the  hand 
does  more  than  an  hour's  conversation.  The  more  simple 
and  natural  the  care,  the  less  design  does  the  patient 
see  therein,  and  the  better  for  him.  But  unfortunately  it 
is  usually  impossible  to  be  uniformly  quiet  and  sympa- 
thetic for  months,  when  the  individual's  own  heart  is 
bleeding  for  the  patient,  and  then  again  the  other  injuri- 
ous influences  of  the  outer  world  cannot  be  entirely  ex- 
cluded in  the  family.  The  simplest  method  of  obtaining 
the  desired  rest  for  the  patient  is  to  keep  him  in  bed. 
This  removes  him  from  the  injurious  influences  of  his 
work  and  of  evidences  of  excessive  tenderness,  and  at  the 
same  time  secures  the  necessary  rest  for  the  body.  Mild 
cases,  however,  generally  refuse  to  go  to  bed,  and  in  these 


SUICIDE.  199 

special  cases  we  may  occasionally  permit  a  change  of 
scene,  under  the  care  of  a  good  nurse. 

As  a  general  thing,  however,  such  measures  are  insuf- 
ficient and  asylum  treatment  is  indicated.  This  becomes 
absolutely  imperative  whenever  we  have  reason  to  fear 
suicide,  acts  of  violence  of  other  kinds,  or  a  refusal  to  take 
food.  In  truth  every  melancholic  must  be  regarded  as 
capable  of  committing  suicide,  and  although  this  suspicion 
must  not  be  carried  too  far — the  rest  of  the  family  should 
not  act  as  spies  upon  the  patient,  because  the  home  condi- 
tions cannot  prevent  a  well-planned  suicide — yet  the  phy- 
sician- must  never  lose  sight  of  this  danger  and  must 
transfer  the  patient  to  an  asylum  in  time. 

If  the  patient  must  remain  at  home,  it  is  to  be  remem- 
bered that  attempts  at  suicide  are  made  chiefly  in  the 
early  morning  hours.  If  constant  supervision  is  imprac- 
ticable, then  the  patient's  hands  must  be  restrained 
mechanically.  Nobody  will  deny  the  necessity  of  such 
measures  when  a  physician  or  asylum  aid  cannot  be 
quickly  secured.  But  then  it  becomes  the  duty  of  the  phy- 
sician to  insist  upon  immediate  admission  to  an  asylum. 

Next  in  importance  to  mental  and  bodily  rest  in  the 
treatment  of  melancholia  is  the  regulation  of  sleep.  Usu- 
ally the  physician  resorts  at  once  to  the  administration  of 
drugs.  But  it  must  be  remembered  that  the  patient  may 
not  take  medicines  on  account  of  the  fear  of  poisoning, 
and  on  the  other  hand  their  continued  admintstration 
during  a  long  illness  may  prove  injurious.  As  a  matter 
of  course,  a  sedative  must  be  occasionally  given  if  we 
must  quiet  temporary  excitement  in  order  to  render  possi- 
ble the  transfer  of  the  patient  to  an  asylum.  But  this  is 
a  form  of  restraint  and  is  not  a  curative  measure.  We 
may  speak  of  medicinal  treatment  only  when  a  drug  is 
given  according  to  some  definite  plan,  not  when  it  is  used 
now  and  then  to  combat  individual  symptoms.  Above 
all,  the  physician  should  not  make  experiments  with  any 
of  the  innumerable  new  drugs,  whose  action  is  still  imper- 
fectly understood.     The  number  of  tried  remedies  is  small. 


200  HANDBOOK   OF  INSANITY. 

The  best  sedative  and  hypnotic  in  melancholia  is  morphine 
or  opium.  In  solution  morphine  may  be  given  unnoticed 
in  the  food ;  when  the  patient  becomes  suspicious,  hypo- 
dermic injections  may  be  used.  The  regular  daily  dose 
of  one  to  two  centigrams  will  suffice,  and  more  than  three 
centigrams  should  hardly  ever  be  given.  Combined 
with  2.0  grams  chloral  hydrate  at  night,  morphine  is  an 
effective  hypnotic,  while  chloral  alone  is  much  less  useful 
and  after  a  while  produces  disagreeable  effects  (headache 
and  dulness  during  the  day) .  In  females,  opium  appears 
to  act  better  than  morphine.  Protracted  anxious  restless- 
ness of  moderate  degree  and  general  anaemia  indicate  the 
use  of  opium.  This  is  given  in  powder,  at  first  two  cen- 
tigrams two  or  three  times  a  day,  and  then  increasing  in 
a  few  days  to  two  or  three  times  this  amount,  until  nota- 
ble sedation  is  effected. 

In  special  cases  other  remedies  may  occasionally  be  re- 
sorted to,  and  we  refer  to  the  article  on  general  treatment. 
We  may  here  mention  the  use  of  mild  alcoholic  drinks, 
such  as  beer,  wine,  or  punch.  Prolonged  warm  baths  are 
very  serviceable,  and  may  be  replaced  occasionally  by  wet 
packs.  In  severe  excitement  and  prsecordial  fears  the  last 
method  has  very  little  effect,  and  we  must  then  resort  to 
more  rapidly  acting  remedies,  particularly  to  morphine. 

The  more  severe  the  disease  the  less  effect  will  be  pro- 
duced by  direct  treatment  with  drugs,  and  the  chief  atten- 
tion must  then  be  paid  to  the  nutrition  and  hygienic 
measures.  The  necessity  of  artificial  feeding  is  always  a 
decisive  reason  for  bringing  the  patient  to  an  asylum. 
When  food  is  freely  taken,  it  should  be  as  nutritious  as 
possible.  All  the  organs  must  be  carefully  examined,  and 
any  diseases  which  may  be  present  should  receive  appro- 
priate treatment.  The  immobile  melancholic  must  be  led 
around  a  good  deal  in  the  open  air,  the  anxiously  excited 
patient  should  be  kept  in  bed.  Both  must  receive  frequent 
baths,  both  for  purposes  of  cleanliness  and  also  to  stimulate 
the  activity  of  the  skin  and  heart.  During  convalescence, 
but  only  at  that  period,  the  patient  may  receive  the  com- 


DESCRIPTION  OF  PLATE  I. 

Comparison  with  the  exposed  facial  muscles  in  an  anatomical 
atlas  is  advisable  in  examining  these  plates. 

MELANCHOLIA. 

Upon  the  brow  of  the  young  melancholic  who  dreads  decapita- 
tion is  seen  distinctly  a  horizontal  fold  of  the  frontal  integument, 
only  in  the  middle  above  the  root  of  the  nose.  This  restriction  of 
the  contraction  of  the  frontal  muscle  to  its  middle  bundles  is  very 
common  in  the  expression  of  grief,  but  the  brow  of  the  man  to  the 
right  and  above  exhibits  complete  transverse  furrowing ;  this  was 
also  a  true  profound  melancholia. 

Other  muscles  also  act  to  produce  the  expression  of  grief.  The 
two  corrugators  bring  the  eyebrows  closer  together,  and  hence  ver- 
tical folds  form  over  the  root  of  the  nose.  But  as  the  frontal 
muscle  often  acts  more  strongly  upward,  the  inner  extremity  of 
the  eyebrow  is  occasionally  raised ;  this  is  shown  very  well  in  the 
lower  half  figure,  in  which  the  forehead  is  wrinkled  only  on  one 
side  (this  was  not  taken  from  a  melancholic  patient) .  Then  the 
upper  lids,  which  usually  hang  down  flabbily,  also  appear  curved. 
This  is  also  effected  by  contraction  of  the  orbicularis  palpebrarum, 
which  at  the  same  time  causes  wrinkling  of  the  skin  of  the  outer 
angle  of  the  eye  (compare  the  picture  of  the  woman  on  the  right) . 
The  combination  of  the  contraction  of  the  three  groups  of  muscles 
mentioned  produces  the  careworn  expression  of  the  upper  half  of 
the  face ;  perhaps  the  pyramidal  muscle  of  the  nose  also  takes  part 
by  its  lessened  activity,  because  the  antagonistic  middle  bundles 
of  the  frontal  muscle  may  then  act  more  vigorously  in  an  upward 
direction.  At  all  events,  the  resultant  right-angled  furrowing  of 
the  forehead  is  to  be  regarded  as  a  sign  of  melancholia. 

A  less  constant  feature,  but  one  which  materially  increases  the 
melancholic  expression,  is  the  marked  character  of  the  naso-labial 
folds.  This,  almost  alone,  imparts  a  sorrowful  appearance  to  the 
lower  half  of  the  face  in  the  picture  of  the  woman,  but  that  ex- 
pression is  due  mainly  to  the  drooping  of  the  angles  of  the  mouth 
and  the  protrusion  of  the  lower  lip.  This  woman  had  torn  the 
hair  from  her  head  in  her  great  fear  ;  the  folded  hands  intensify  the 
general  anxious  expression. 


HANDBOOK  OF  INSANITY. 

KIRCHHOFF. 


Plate  I. 


-a-; 


REMOVAL   FROM   ASYLUM.  201 

forts  of  religion.  At  this  time  positive  psychical  treat- 
ment is  again  indicated.  Terrifying  delusions  may  now 
be  shaken  by  reasoning.  Even  if  logic  is  not  of  much 
avail,  the  convalescent  is  thankful  for  the  well-meant 
efforts,  and  he  regains  more  rapidly  the  necessary  self-sup- 
port if  he  feels  himself  aided  by  others. 

Should  a  convalescent  melancholic  be  removed  from  the 
asylum  as  early  or  as  late  as  possible?  Usually  the  family 
physician  needs  to  exert  his  influence  against  too  early 
removal,  because  the  danger  of  suicide  in  unexpected  at- 
tacks of  fear  may  again  be  encountered.  Complete  recovery 
alone  furnishes  full  security.  In  individual  cases,  how- 
ever, an  early  removal  may  be  advisable.  If  a  family 
thereby  secures  its  support  so  much  earlier,  and  if  the  pa- 
tient derives  satisfaction  from  providing  for  those  depend- 
ent on  him,  if  a  satisfactory  activity  awaits  him  at  home, 
then  his  dismissal  from  the  asylum  is  indicated.  It  may 
also  be  desirable  to  place  a  well-to-do  patient  under  better 
climatic  surroundings  than  he  will  find  at  home.  If  he  re- 
covers entirely  in  some  other  locality,  his  return  to  his 
former  pursuits  is  facilitated  in  view  of  the  prejudice 
against  patients  who  have  been  in  an  asylum.  If  the 
patient  has  furnished  proof  of  his  recovery  under  other 
conditions,  he  is  received  at  home  with  greater  confidence. 
The  family  should  receive  him  as  unconcernedly  as  possi- 
ble, and  should  act  toward  him  as  toward  his  former 
self.  Hence  they  may  speak  concerning  his  disease,  be- 
cause he  does  this  willingly  and  manifests  gratitude  for 
the  care  and  kind  treatment  bestowed  upon  him.  If  a 
melancholic  returns  home  quiet,  but  not  recovered,  he 
must  be  treated  as  a  patient  and  treated  in  the  manner 
already  indicated. 

B.    MANIA. 

A  morbidly  elated  mood  constitutes  the  fundamental 
basis  of  mania,  varying  from  slight  cheerfulness  to  violent 
rage.  It  is  accompanied  constantly  by  an  accelerated 
flow  of  ideas,  and  by  more  or  less  accelerated  conversion 


202  HANDBOOK  OF   INSANITY. 

of  conditions  of  mental  excitement  into  acts,  while  disor- 
ders of  consciousness,  including  hallucinations,  usually 
appear  only  in  the  higher  grades  of  the  disease.  Stress 
should  be  laid  on  the  fact  that  in  mania,  which  occurs  in- 
dependently, the  symptoms  all  develop  upon  the  same 
morbid  basis,  not  alone  in  psychological  dependence  upon 
one  another.  For  example,  the  cheerful  mood  does  not 
depend  upon  the  facilitated  flow  of  ideas.  It  is  probable 
that  congestion  and  disturbed  chemical  changes  in  the 
cortex  form  the  common  anatomical  basis.  Mania  has  an 
organic  basis,  although  this  cannot  often  be  demonstrated 
and  it  is  therefore  customary  to  call  it  a  functional  disease. 
The  greater  the  lack  of  inhibition  of  the  mental  processes. 
and  the  resultant  actions,  the  more  the  originally  cheerful 
mood  is  converted  into  a  violent,  indeed  angry  excitement, 
in  which  there  may  finally  be  an  impairment  of  conscious- 
ness. 

The  prodromata  of  mild  maniacal  excitement  are  accom- 
panied quite  constantly  by  a  sorrowful  mood,  which  may 
be  regarded  as  an  expression  for  the  feeling  of  the  newly 
developing  irritant,  which  appears  foreign  and  incom- 
prehensible to  the  patient.  Sometimes  this  melancholy 
phase  cannot  be  distinguished  from  a  mild,  independent 
melancholia.  The  patient  is  quiet,  depressed,  suffers  from 
general  malaise,  insomnia,  attended  with  digestive  dis- 
turbances and  emaciation. 

In  a  few  weeks  these  symptoms  disappear,  and  the  pa- 
tient believes  the  threatened  danger  is  past,  especially  as 
the  renewed  enjoyment  of  work  and  the  more  cheerful 
mood  are  attended  with  a  better  physical  appearance. 
But  it  soon  becomes  evident  that  this  is  merely  the  begin- 
ning of  a  series  of  morbid  phenomena.  The  first  striking 
feature  is  the  increased  talkativeness,  and  the  greater  in- 
terest in  surrounding  affairs.  The  patient  makes  numer- 
ous calls  upon  friends  and  strangers ;  the  conversation  is 
one-sided — an  answer  is  not  demanded  or  expected,  but 
given  by  the  patient  himself.  The  facilitated  association 
and  accelerated  flow  of  ideas  permit  witty  and  surpris- 


PRODROMES.  203 

ing  turns  of  conversation,  which  under  other  conditions 
must  be  sought  with  difficulty.  The  formerly  modest  in- 
dividual suddenly  becomes  eloquent  in  society ;  after  din- 
ner he  makes  impromptu  poetical  remarks,  and  is 
admired  by  the  majority  on  account  of  his  new  talent. 
If  the  thread  of  conversation  is  occasionally  lost  by  him, 
this  is  usually  excused,  in  a  merry  company,  by  the  influ- 
ence of  wine.  Indeed,  the  cerebral  irritability  is  early 
shown  by  the  fact  that  very  small  amounts  of  alcoholic 
stimulants  are  sufficient  to  produce  excitement. 

In  daily  life,  however,  the  eyes  of  those  around  the  pa- 
tient are  rapidly  opened.  The  restless  activity  and  the 
feeling  of  constantly  increasing  abilities  lead  the  patient 
to  form  plan  after  plan,  although  none  is  carried  to  com- 
pletion. In  addition,  he  writes  numerous  letters;  their 
form  enables  us  to  detect  the  rapidity  of  their  production ;; 
large  letters  run  rapidly  in  bold  curves  across  the  paper, 
underscorings  are  very  numerous,  and  the  contents  corre- 
spond to  the  flow  of  ideas,  although  the  restraint  of  the 
slower  writing-concepts  still  curbs  the  contents  to  a  cer- 
tain extent. 

Even  at  this  time  many  are  mistaken  and  admire  the 
patient's  bold  thoughts,  despite  various  offences  against 
propriety  which  he  commits.  Nor  can  it  be  denied  that 
the  fancy  of  mild  maniacal  excitement  may  be  an  attractive 
phenomenon,  although  it  furnishes  little  real  power  of 
imagination.  It  must  be  remembered  that  the  mental 
activity  of  the  patient  does  not  run  in  the  customary  tracks ; 
that,  as  a  rule,  he  does  not  care  whether  he  is  regarded 
as  cranky  or  peculiar,  and  that  he  has  lost  the  finer 
considerations  of  social  propriety.  His  imagination  acts 
without  object  or  restraint.  He  sees  his  ideas  arrange 
themselves  involuntarily,  according  as  they  are  aroused 
by  impressions  of  this  or  that  sense.  At  times,  the  pa- 
tient's look  indicates  a  condition  of  poetic  inspiration, 
and,  after  his  recovery,  he  may  relate  wonderful  dream- 
like experiences. 

In  mania  we  can  follow  the  paths  along  which  ideas 


204  HANDBOOK   OF   INSANITY. 

and  words  are  mentally  combined,  because  conscious  se- 
lection is  absent,  and  the  patient  is  left  involuntarily  to 
the  play  of  his  thoughts.  The  careful  consideration  of 
speech  in  mania  throws  some  light  upon  this  form  of  as- 
sociation of  ideas.  There  are  two  different  methods  of 
association,  one  according  to  the  sound  of  the  words,  the 
other  according  to  the  relationship  of  ideas.  Thus,  a 
patient  who  hears  the  ringing  of  a  bell,  begins  to  rhyme 
with  words  like  well,  dell,  sell,  hell.  In  the  other  method 
the  name  of  a  person  which  reminds  the  patient  of  the 
idea  of  a  fish,  rapidly  gives  rise  to  ideas  of  shell-fish, 
oysters,  fisheries'  exhibitions,  etc.  As  a  general  thing, 
both  modes  of  association  are  employed.  The  patient  says 
this  house  is  made  of  wood  and  stone ;  wood  is  an  article  of 
fuel ;  the  fire  is  hot,  etc.  On  account  of  such  jumps  the 
accelerated  flow  of  ideas  often,  apparently,  loses  its  inter- 
nal connection,  but  the  consideration  of  the  mode  of 
speech  shows  us  that  this  so-called  flight  of  ideas  does  not 
occur  entirely  without  internal  connection.  But  our 
knowledge  of  the  connection  of  the  thoughts  is  entirely 
unsatisfactory,  and  we  can  detect  only  small  bits  in  the 
structure  of  the  thoughts  within  the  patient's  mind.  As 
in  dreams  the  boldest  flights  of  thought  pass  across  our 
mind  without  arousing  the  slight  feeling  of  their  disjointed 
character,  so  the  same  thing  may  occur  in  mania.  As  a 
rule,  the  mental  processes  are  entirely  clear  to  the  patient. 
In  a  flight  of  ideas  of  a  moderate  grade,  the  mood  is 
mainly  a  cheerful  one.  The  fact  that  his  thoughts  come 
voluntarily,  without  effort,  increases  the  patient's  satisfac- 
tion, and  makes  him  look  hopefully  into  the  future.  But 
this  mood  is  not  uniform,  and  even  cautious  opposition 
will  produce  a  violent  manner  and  evidences  of  irritation. 
Such  impressions,  however,  are  very  brief,  and  the  mirth 
soon  comes  again  to  the  front.  This  varying  mood  and 
irritability  now  removes  all  doubt  in  the  minds  of  the 
family  concerning  the  morbid  character  of  the  condition. 
"When  the  patient  will  not  tolerate  the  slightest  opposition 
without  cursing  and  shouting,  or  destroying  clothing  and 


MANIACAL   GESTURES.  205 

furniture,  the  patience  of  the  family  becomes  exhausted, 
and  the  physician  is  summoned.  The  anger  of  the  pa- 
tient is  not  excited  by  external  causes  alone.  An  out- 
break of  angry  excitement  often  appears  in  the  midst  of 
unbridled  mirth,  but  soon  returns  to  the  previous  condi- 
tion. In  a  similar  way  we  often  notice,  at  this  period,  a 
temporary  depressed  mood,  with  violent  crying  and  com- 
plaining, and  for  which  not  the  slightest  external  cause 
can  be  found.  This  also  subsides  rapidly,  and  the  domi- 
nant mood  remains  cheerful. 

The  gestures  soon  excite  the  interest  of  the  observer, 
not  alone  the  play  of  the  features,  but  also  the  movements 
which  accompany  impulses  and  acts.  The  play  of  fea- 
tures is  lively,  the  eye  is  bright,  the  skin  often  reddened. 
At  the  height  of  the  disease  there  is  no  doubt  that  the  pa- 
tient cannot  control  the  facial  expression.  Distortions  and 
even  spasmodic  twitchings  accompany  the  increase  of  ex- 
citement, and  it  becomes  evident  that  the  facial  movements, 
like  the  impulses  and  acts,  are  not  alone  free  from  inhi- 
bition, but  take  place  as  the  direct  result  of  irritative  con- 
ditions in  the  cerebral  cortex.  In  mild  mania  all  active 
gestures  result  from  the  excitability,  but  their  impulsive 
character  may  still  be  regulated  and  checked.  The  ex- 
ternal activity  is  also  confined,  in  great  part,  to  customary 
channels.  For  example,  the  patient  walks  about  to  an 
unusual  degree,  but  he  is  apt  to  conceal  his  restlessness  by 
the  statement  that  walking  is  very  necessary  and  healthful. 
Another  makes  long  trips,  foolhardy  boating  excursions, 
or  exhausts  himself  in  mountain  climbing.  The  motor 
restlessness  is  manifested  in  a  less  serious  manner  by  use- 
less packing  and  unpacking  of  books,  or  constant  fussing 
among  old  papers,  under  the  pretext  of  putting  things  in 
order.  Women  busy  themselves  with  their  toilet,  or  make 
daily  changes  in  the  arrangement  of  their  hair.  To  this  is 
soon  added  increased  coquetry.  They  dress  themselves 
fantastically,  the  manner  becomes  more  self-complacent, 
and  they  often  have  a  tendency  to  display  their  superiority, 
especially  by  singing  and  acting  before  large  audiences. 


206  HANDBOOK   OF   INSANITY. 

In  the  female  sex  the  sexual  impulse  soon  pushes  into  the 
foreground.  Acquired  modesty  ma}T  veil  its  manifesta- 
tions, so  that  it  first  appears  under  other  forms — for  ex- 
ample, in  the  shape  of  accusations  against  other  women 
or  the  tendency,  on  every  occasion,  to  speak  with  the  phy- 
sician about  menstruation,  etc.  Such  subjects  of  conver- 
sation are  apt  to  be  associated  with  excessive  devotion  to 
religious  exercises.  At  a  later  period  the  excitement  is  re- 
vealed more  clearly  by  protestations  of  love,  and  finally  by 
shameless  offers  of  sexual  intercourse.  In  men  sexual  ex- 
citement is  less  marked,  probably  because  it  can  be  grati- 
fied by  them,  without  difficulty,  in  houses  of  prostitution. 
But  the  same  tendency  appears  in  their  conversation,  and 
is  shown  particularly  by  double  entendres  and  smutty 
jokes.  Masturbation  is  kept  more  concealed  in  both  sexes. 
In  slighter  grades  of  excitement  we  find  only  an  excessive 
dressiness,  the  reading  of  lascivious  novels,  attempts  to 
touch  the  bodies  of  persons  of  the  opposite  sex  or  merely 
to  come  in  contact  with  their  clothes. 

During  this  stage  there  is  often  observed,  in  men,  an 
excessive  addiction  to  stimulants,  but  this  is  probably  due  to 
their  opportunities,  inasmuch  as  the  maniac  likes  society 
and  his  mood  is  intensified  by  alcoholic  drinks.  As  a  rule, 
very  slight  amounts  produce  intoxication. 

Nor  may  we  speak  of  an  impulse  for  collecting  articles 
in  describing  an  activity  which  results,  independently  of 
the  will,  from  direct  psychomotor  irritants.  There  are  no 
delusions  as  intervening  links,  but  the  removal,  even  theft, 
of  articles  is  an  expression  of  restlessness  which  finds  sat- 
isfaction in  the  purposeless  grasping  of  such  objects. 

In  the  milder  grades  of  mania,  delusions  and  hallucina- 
tions are  rare.  The  mistakes  which  the  patients  make  in 
the  personality  of  others  are  due,  as  a  rule,  to  insufficient 
observation,  so  that  a  partial  likeness  suffices  to  produce 
the  deception.  In  the  same  way  sounds  are  rapidly  worked 
up  into  definite  ideas.  Hence  we  have  to  deal  with  illu- 
sions, not  with  peripheral  or  central  hallucinations. 

Although  all  these   phenomena    indicate  an  increased 


FRENZY.  207 

activity  of  the  nervous  system,  the  income  is-  soon  less  than 
the  output.  The  excited  patient  often  forgets  hunger  and 
thirst,  chooses  improper  food,  and  these  factors,  together 
with  the  loss  of  sleep,  soon  result  in  loss  of  weight  which 
proves  the  impaired  nutrition.  Although  the  feeling  of 
exhaustion  is  absent  even  after  great  bodily  efforts,  yet  the 
very  increase  of  excitability  is  an  evidence  of  exhaustion  of 
the  nerve  power.  The  pulse  is  moderately  accelerated. 
The  menses  are  often  absent,  but  this  has  no  particular 
significance. 

Thus  far  we  have  considered  only  the  symptoms  of  the 
milder  grades  of  independent  mania.  The  disease  may 
remain  at  the  height  indicated  for  several  weeks  or  months 
and  then  pass  gradually  into  recovery,  or  it  may  lead  to 
the  symptoms  known  as  frenzy  from  the  prominence  of  the 
unbounded  motor  excitement.  But  as  other  insane,  es- 
pecially melancholies  during  attacks  of  fear,  also  grow 
frenzied,  we  prefer  to  use  the  term  mania,  because,  con- 
sidering the  different  violence  of  the  individual  symptoms, 
the  severer  conditions  of  manial  excitement  have  the  same 
symptoms  as  the  milder  grades  already  described.  But  it 
must  be  noted  that,  after  the  preliminary  melancholic  stage, 
severe  mania  passes  much  more  rapidly  through  the 
milder  degree  of  excitement,  and  the  symptoms  proper 
rapidly  attain  their  complete  development.  The  more 
prolonged  and  profound  the  depressed  mood  the  greater 
are  the  duration  and  violence  of  the  following  mania. 

The  direct  manifestations  of  the  irritative  condition  of 
the  cortex  can  be  recognized  much  more  distinctly  in  all 
the  symptoms  of  severe  mania.  Hence  the  psychomotor 
movements  occupy  the  foreground,  and  numerous  hallu- 
cinations and  delusions  appear  directly,  without  any  at- 
tempt at  explanation.  Although  only  the  very  highest 
grades  of  severe  mania  are  accompanied  by  more  lasting 
anatomical  changes  in  the  brain,  yet  in  some  cases  the  ac- 
companying physical  symptoms  show  the  marked  irrita- 
tion of  the  nervous  system.  Hence  these  few  cases  do  not 
justify  the  creation  of  a  special  group,   distinguishable 


208  HANDBOOK   OF   INSANITY. 

under  the  term  acute  delirium  from  simple  functional 
mania.  Nor  do  I  feel  justified  in  accepting  a  group 
known  as  hallucinatory  confusion,  on  account  of  the  very 
great  prominence  of  hallucinations,  because  these  cases 
also  exhibit  the  other  symptoms  of  mania. 

At  the  height  of  its  development,  then,  severe  mania 
exhibits  enormous  motor  restlessness.  The  motor  impulse 
of  the  patient  is  discharged  in  entirely  irregular  move- 
ments. There  is  no  longer  any  question  of  actions  with  a 
definite  purpose.  Perfect  regardlessness  in  movements 
and  actions;  ceaseless,  uniform  activity  by  night  and 
day,  are  the  signs  of  this  motor  excitement,  the  patient 
attacking  every  obstacle  with  violence,  and  regardless  of 
consequences.  Convalescents  or  others  who  still  possess 
a  certain  amount  of  reason  occasionally  state  during  the 
attack  that  they  cannot  do  otherwise,  that  they  must 
dance  and  jump  and  tear  things.  The  frenzy  is  increased 
by  the  necessity  of  restraining  the  patient's  liberty,  and 
doors  and  windows  are  frequent  objects  of  attack.  But 
if  the  restraint  is  moderate  and  destructible  objects  are 
not  within  reach,  the  motor  excitement  is  often  expended 
in  a  less  harmful  manner.  Laughing  and  crying,  singing 
and  whistling,  clapping  his  hands,  the  patient  jumps  and 
dances  around  the  room,  cleans  up  along  the  floor,  the  walls 
and  windows;  if  supervision  is  insufficient,  he  washes 
himself  with  his  own  urine ;  then  he  drums  upon  the  door, 
beats  the  table,  overturns  a  bench,  and  makes  rapid  turns 
around  the  room,  laughing  and  shouting.  He  overturns 
other  persons,  and  takes  from  them  some  utensil,  merely 
to  throw  it  away  in  a  moment.  Or  he  dresses  and  un- 
dresses with  rapidity,  cuts  his  clothing  or  bedding  into 
narrow  strips  which  are  placed  fantastically  upon  his  per- 
son. A  turban  of  rags  or  twisted  bundles  of  straw 
adorns  his  head,  the  articles  of  clothing  are  placed  on  the 
wrong  parts  of  the  body,  the  shoes  and  stockings  are 
thrown  away,  again  collected,  and  ball  is  merrily  played 
with  them.  Leaves  are  placed  in  every  buttonhole. 
All  attainable  objects  are  picked  to  pieces  and  then  re- 


HALLUCINATIONS.  209 

constructed  into  new  ones.  The  patient  collects  all  sorts 
of  useless  objects — stones,  pieces  of  wood  and  glass,  nails, 
shreds  of  paper,  spoons,  forks  —  fills  his  pockets  with 
them,  and  uses  them  for  all  sorts  of  foolish  notions.  The 
walls,  furniture,  and  windows  are  scratched  or  besmeared, 
and  drawings  are  made  upon  the  floor  or  table.  Plastic 
works  of  art  of  a  very  doubtful  value  are  made  from  chewed 
pieces  of  bread  or  other  soft  material.  The  patient  is  con- 
stantly entering  into  new  plans,  admiring  in  the  highest 
degree  his  own  skill.  At  the  same  time  he  is  usually 
outside  the  hurlyburly,  as  it  were,  and  perhaps  remarks 
ironically,  when  his  follies  are  opposed,  that  he  is  allowed 
to  do  anything  because  he  is  crazy. 

This  condition  may  last,  without  any  feeling  of  ex- 
haustion, for  weeks,  hardly  interrupted  for  hours  by  rest- 
less sleep  or  by  a  feebler  frenzy  for  a  few  minutes  when 
exhaustion  begins  to  be  manifest.  The  flight  of  ideas  is 
often  partly  obliterated,  but  is  still  manifest  by  certain 
phrases  and  words.  The  incoherence  now  increases  to  the 
highest  grades,  because  the  already  overfilled  conscious- 
ness very  often  receives  constantly  new  impressions  from 
numerous  hallucinations.  These  are  very  changeable, 
chiefly  of  a  pleasant  character,  but  very  often  interspersed 
with  frightful  ones.  They  are  accompanied  by  a  very 
rapid  change  of  mood.  True  central  hallucinations,  es- 
pecially visual,  develop.  Series  of  shapes  in  gaudy  attire 
pass  by ;  they  talk  and  sing  in  front  of  the  window.  The 
vividness  of  these  phenomena  induces  the  patient  to  take 
part  in  the  play ;  for  some  moments  he  speaks  theatrically 
in  long  periods,  then  listens,  speaks  again,  then  suddenly 
laughs  and  jumps  about,  because  the  scene  no  longer  in- 
terests him.  The  vividness  may  be  so  great  that  an  indi- 
vidual who  enters  the  room  does  not  interrupt  the  dialogue, 
but  a  role  is  assigned  to  him.  Incoherence  is,  however, 
generally  manifested  so  that  the  spectator  is  unable  to 
follow  the  association  of  ideas.  Hence  the  delusions, 
which  are  chiefly  nourished  by  the  hallucinations,  are 
rather  remarks  en  passant  than  firm  opinions.  The  de- 
14 


210  HANDBOOK  OF   INSANITY. 

lusions  are  fleeting,  and  develop  in  great  measure  on  the 
basis  of  the  increased  self-esteem.  Some  patients  declare 
themselves  princes  or  kings,  but  an  internal  systematiza- 
tion  of  such  fancies  hardly  ever  takes  place.  Frightful 
hallucinations  and  delusions  also  develop  at  times  and 
force  angry  affects  into  the  foreground.  Hallucinations  of 
taste,  smell,  and  feeling  are  more  often  in  a  disagreeable 
than  in  an  agreeable  association.  They  also  return  some- 
what more  constantly  in  the  course  of  mania  and  then 
lead  to  an  increase  of  the  refusal  to  take  food,  which  is 
already  pronounced  in  the  excited  patient ;  the  fear  of  poi- 
soning now  makes  its  appearance.  In  women  (and  un- 
doubtedly in  connection  with  the  approach  of  menstrua- 
tion) hallucinations  of  the  lower  senses  increase  and  cause 
disagreeable  sensations  which  lead  to  great  excitement 
and  indeed  to  violent  attacks.  Other  female  patients 
revel  in  maternal  feelings,  rock  a  pillow  upon  the  arm, 
lay  it  lovingly  upon  the  breast,  but  soon  remove  it  to 
begin  another  occupation. 

In  severe  mania  the  fleeting  and  confused  character  is 
common  to  all  hallucinations,  illusions,  and  delusions, 
whether  of  an  agreeable  or  disagreeable  nature.  This  be- 
comes more  marked  the  more  violent  the  disease,  and  in 
the  highest  grades  they  lose  their  distinctness  to  the  ob- 
server. The  patient  now  rolls  and  twists  upon  the  floor, 
stamps  his  feet,  claps  his  hands,  beats  time  upon  the  floor, 
blows  violently.  Indistinguishable  syllables  and  sounds, 
detached  parts  of  sentences  and  outcries,  are  strung  to- 
gether in  a  disconnected  series ;  inarticulate  cries  and  moans 
are  uttered  with  foaming  mouth,  and  this  is  only  stopped 
by  complete  hoarseness.  Irregular  twitchings  of  the  face 
and  limbs,  gnashing  of  the  teeth,  stammering  speech,  and 
detached  irregular  clonic  convulsions  show  the  implication 
of  the  psychomotor  centres,  and  such  cases  are  usually  at- 
tended with  high  temperature  and  acceleration  of  the 
pulse. 

General  sensibility  seems  to  be  diminished  and  but  little 
attention  is  paid  to  pain.     The  patient  does  not  notice  the 


DIMINISHED    SENSIBILITY.  211 

numerous  slight  injuries  which  result  from  his  own  vio- 
lence ;  even  more  serious  wounds  remain  unnoticed,  or  the 
patient  tears  off  the  bandages,  and  uses  them  in  sport. 
Another  runs  around  naked  in  a  cold  room,  or  is  exposed 
for  hours  to  the  direct  heat  of  the  sun.  This  insensibility 
is  probably  due  to  lack  of  attention.  The  patient  must  be 
guarded,  however,  against  all  such  injurious  irritants,  be- 
cause they  undoubtedly  enter  into  the  course  of  his  ideas 
and  aggravate  the  disease.  In  temporary  remissions  of 
mania  we  learn  that  he  is  able  to  distinguish  heat  and 
cold  and  is  susceptible  to  all  changes  in  the  condition  of 
his  body ;  occasionally  he  complains  of  headache  and  for 
brief  moments  even  has  a  distinct  feeling  that  he  is  ill. 

A  peculiar  phenomenon  is  the  absence  of  the  feeling  of 
satiety,  although  it  is  not  very  frequent  at  the  height  of 
the  disease.  This  is  probably  an  expression  of  the  very 
extensive  nutritive  changes  in  the  body,  and  the  often  in- 
sufficient supply  of  food.  Much  more  frequently  no  at- 
tention is  paid  to  the  food  offered,  and  occasionally  there 
is  even  a  decided  refusal  of  food,  following  hallucinations 
of  smell  and  taste.  This  is  soon  followed  by  catarrh  of  the 
digestive  tract,  constituting  a  very  grave  symptom  which 
precedes  an  unfavorable  course  and  death  by  exhaustion. 

If  fever  appears — often  in  consequence  of  the  numerous 
wounds — the  entire  breakdown  of  the  vital  forces  is  usu- 
ally very  rapid.  This  condition  is  accompanied  by  a 
rapid,  irregular,  or  dicrotic  pulse. 

In  general,  however,  the  pulse  is  quite  regular  in  severe 
mania,  and,  like  the  temperature,  is  changed  only  by  ac- 
cidental complications.  But  in  the  severest  cases,  which 
are  attended  by  meningitic  irritative  symptoms,  paralytic 
symptoms  occur  at  times,  due  probably  to  cerebral  oedema. 

As  a  general  thing,  there  are  fluctuations  in  the  severity 
of  the  symptoms.  These  fluctuations  appear  to  be  so 
much  less  pronounced,  the  more  violent  and  rapid  the  en- 
tire course  of  the  disease. 

A  fully  developed  case  of  mania,  in  which  the  symp- 
toms  are   moderate   in  severity,   usually   remains  at  its 


212  HANDBOOK   OF   INSANITY. 

height  for  several  months,  and  at  least  six  months  elapse 
before  the  disease  has  run  its  course.  Cases  have  been 
reported  in  which  the  attack  ceased  in  a  few  days  or  even 
hours ;  but  it  must  be  remembered  that  an  hysterical  or  epi- 
leptic basis  could  often  be  demonstrated,  or  that  they  were 
due  to  intoxications  or  febrile  delirium.  At  all  events  we 
must  be  very  cautious  in  accepting  an  independent  so-called 
transitory  mania.  A  duration  longer  than  six  mouths 
does  not  exclude  recovery,  which  may  occur  at  the  end  of 
a  year,  but  involves  great  danger  of  passing  into  incura- 
ble conditions  of  feeble-mindedness. 

If  the  symptoms  of  mania  still  remain  distinct  the  term 
chronic  mania  is  suitable  in  a  measure,  but  its  appropri- 
ateness is  lost  more  and  more  until  finally  we  may  only 
speak  of  mental  weakness  in  which  violent  excitement  oc- 
casionally develops,  as  the  result  of  accidental  external 
causes.  Finally,  these  are  merged  into  quiet  feeble-mind- 
edness with  a  certain  degree  of  irritability,  into  complete 
dementia,  or  a  loquacious,  confused  condition  is  still  recog- 
nizable as  the  remains  of  true  mania.  But  the  milder  as 
well  as  the  severer  forms  offer  the  best  chances  of  recovery 
among  all  psychoses.  In  the  severe  forms,  however,  a 
considerable  proportion  terminates  in  death  from  exhaus- 
tion. 

The  termination  in  recovery  passes  through  certain  in- 
tervening stages.  In  mania  which  has  developed  indepen- 
dently, recovery  is  never  sudden,  but  more  quiet  hours  and 
days  alternate  with  periods  of  greater  excitement.  Sleep 
improves  and  the  impulse  to  movement  subsides,  while  the 
irregular  association  of  ideas  is  still  evident  from  incohe- 
rent utterances  or  appears  at  least  in  the  shape  of  great 
loquacity.  In  milder  cases  a  certain  recognition  of  the 
morbid  nature  of  the  disease  is  found  in  the  attempt  to  ex- 
cuse this  or  that  irrational  act,  or  tearful  irritability 
alternates  with  cheerful  excitement.  After  severe  mania 
recovery  occasionally  begins  with  periods  of  exhaustion, 
which  may  simulate  rigid  melancholia.  If  this  condition  is 
prolonged,    for  example,   for  several  months,   prognostic 


TERMINATIONS.  213 

importance  attaches  to  the  bodily  weight.  If  this  in- 
creases only  a  little,  it  is  probable  that  the  disease  will  yet 
terminate  favorably,  while  a  rapid  increase  rouses  a  fear 
of  termination  in  incurable  dementia.  In  general,  the 
weight  of  the  body  should  be  carefully  watched.  In  per- 
manent and  complete  recovery  there  is  almost  always  a 
uniform  advance  of  the  mental  and  bodily  functions,  the 
bodily  weight  follows  the  changes  in  the  mental  condition, 
and  hence,  if  the  weight  remains  stationary  for  a  long 
time,  it  is  to  be  feared  that  the  morbid  process  has  not  yet 
run  its  course.  As  a  matter  of  course,  accidental  affec- 
tions of  internal  organs  must  be  taken  into  considera- 
tion. If  there  is  coincident  tuberculosis  we  will  not  ex- 
pect that  the  bodily  nutrition  will  improve  very  greatly 
with  mental  recovery. 

It  may  here  be  noted  that  such  febrile  conditions,  or 
even  febrile  diseases  like  typhoid  fever,  may  exercise  a 
favorable  influence  on  the  course  of  mania. 

The  subsidence  of  the  condition  of  excitement  occasion- 
ally alternates  with  prolonged  melancholic  depression,  and 
this  reminds  us  of  the  beginning  of  the  disease.  Cares 
for  the  future  and  reproaches  concerning  the  acts  done 
during  the  excited  stage  annoy  the  patient,  and  even  mel- 
ancholic delusions  may  appear.  The  mental  activity  is  so 
slight  that  such  ideas  form  a  justifiable  basis  for  their 
fears,  but  they  are  gradually  lost  with  the  increasing  feel- 
ing of  strength.  Now  the  bodily  exhaustion  is  also  felt 
distinctly;  former  neuralgias,  etc.,  sometimes  return  in 
their  accustomed  manner. 

Another  transitional  condition  is  a  foolish,  childish 
loquacity  with  silly  conduct  which  then  passes  slowly 
into  recovery.  But  all  the  transitions  through  dulness 
or  feeble-mindednees,  which  indicate  the  great  exhaustion 
of  the  nervous  system,  may  be  absent  and,  apart  from 
the  frequent  alternations,  there  may  be  a  simple  dimin- 
ution and  gradual  subsidence  of  the  symptoms.  This  is 
favored  most  by  a  few  good  nights'  sleep. 

The  permanent  recognition  of  the  morbid  character  of 


214  HANDBOOK   OF   INSANITY. 

the  disease  is  not  always  attended  with  a  distinct  remem- 
brance of  the  events  of  the  disease ;  the  greater  the  excite- 
ment the  greater  is  the  loss  of  memory.  A  real  hiatus 
of  memory  is  rare,  but  it  is  only  in  the  mildest  cases  that 
the  memory  of  all  details  is  accurate. 

Mania  appears  to  be  a  less  frequent  disease  than  mel- 
ancholia. It  is  most  common  at  the  age  of  twenty  to 
twenty-five  years.  Younger  individuals  are  also  attacked, 
but  its  frequency  diminishes  rapidly  with  advancing  age, 
so  that  old  people  rarely  suffer.  The  only  exception  is  the 
puerperal  condition.  Many  of  these  so-called  puerperal 
manias  are  attended  by  numerous  hallucinations;  they 
are  due  to  anaemia  (from  loss  of  blood) ,  and  their  course  is 
relatively  favorable.  In  general,  however,  sex  exerts 
little  influence  on  the  frequency  of  mania. 

Special  mention  should  be  made  of  the  peculiar  course 
of  mania  in  a  constitutionally  damaged  brain,  whose  func- 
tions were  always  below  par  or  had  become  so  in  the 
course  of  time.  The  disease  is  often  not  very  severe,  is 
very  prolonged,  and  a  disputatious  condition  and  attempts 
at  explanation  of  the  excitement  are  very  prominent.  In 
the  milder  grades  the  mixture  of  healthy  and  morbid  ele- 
ments is  so  pronounced  that  the  laity  and  many  physcians 
deny  the  possibility  of  a  morbid  basis.  But  a  rapid 
though  temporary  increase  to  useless  maniacal  acts  will 
teach  them  differently,  or  careful  observation  reveals  sud- 
den brief  periods  of  depression  among  the  manifestations  of 
cheerful  excitement.  When  such  conditions  are  associated 
with  slight,  often  unrecognized  feeble-mindedness,  they 
occasionally  bring  to  mind  the  so-called  moral  insanity. 
The  tendency  to  interpret  irrational  acts  in  an  apparently 
rational  manner  must  be  regarded  as  an  unfavorable  sign 
in  an  otherwise  mild  mania,  because  the  psychoses  which 
develop  in  a  feeble  brain  have  a  greater  tendency  to  be 
prolonged  and  to  return.  Nevertheless  they  do  not,  as  a 
general  thing,  pass  into  complete  mental  weakness,  even 
after  prolonged  duration,  although  the  higher  intellectual 
faculties  distinctly  diminish. 


DESCRIPTION  OF  PLATE  II. 

MANIA. 

The  characteristic  feature  of  the  expression  is  the  mobility  and 
variety,  although  cheerfulness  predominates.  Hence  it  is  difficult 
to  retain  details  and  our  pictures  show  but  few  forms  of  expression. 
The  painful  melancholic  affect  makes  firm  traces  in  the  integument 
of  the  face,  while  this  is  moved  very  fleetingly  in  maniacal  excite- 
ment, and  it  can  only  be  comprehended  when  the  play  of  physiog- 
nomy is  attributed  to  its  causes  in  the  brain  itself.  The  disturb- 
ances in  the  circulation  and  nutrition  of  the  brain,  especially  of 
its  cortex,  lead,  through  the  excess  of  nervous  activity,  to  unre- 
strained forms  of  expression  in  which  there  is  much  that  is  super- 
fluous. The  two  pictures  of  the  young  man  therefore  give  only  a 
flint  idea  of  his  constant  grimaces,  which  were  continually  inter- 
rupted by  laughing  and  chattering,  by  movements  of  the  head  and 
body.  The  cheerful  expression  of  the  young  girl  permits  a  better 
resolution  into  the  movements  of  individual  muscles.  The  palpe- 
bral fissure  becomes  smaller  from  contraction  of  the  orbicularis 
palpebrarum,  and  at  the  same  time  the  contraction  of  the  levators 
dravv  s  the  upper  lip  upward  ;  the  zygomatics  open  the  mouth  and 
draw  its  angles  upward  and  backward,  so  that  the  teeth  are  ex- 
posed. The  more  movable  skin  of  the  old  man  permits  the  same 
effects  to  be  seen  more  distinctly  in  various  folds ;  hence  we  find 
wrinkles  of  the  lower  lids  and  outer  angles  of  the  eyes  and  trans- 
verse folds  at  the  root  of  the  nose,  because  the  cheeks  and  upper 
lip  are  raised.  The  transverse  wrinkles  on  the  forehead  are  acci- 
dental ;  in  cheerful  affects,  as  a  rule,  the  forehead  becomes  smooth. 
The  brightness  of  the  eye,  which  results  from  congestion  and  pres- 
sure of  the  adjacent  muscles,  is  very  often  an  essential  feature  of 
cheerful  excitement.  As  is  well  known,  the  expression  of  greatest 
joy  approaches  that  of  weeping  and  pain;  the  girl's  folded  hands 
also  show  this  relationship. 

On  account  of  the  restlessness  of  the  bodily  movements  I  have 
been  unable  to  photograph  anger   and   the   more   violent  passions. 
It  must  not  be  forgotten  that  the  facial  expression  is  materially 
changed  by  the  position  and  movement  of  the  entire  body. 


HANDBOOK  OF  INSANITY. 

KIRCHHOFF. 


Plate  II. 


%  .^\N 


■■&*»■*' 


^ 


RESTRAINT  AND   HYPNOTICS.  215 

Even  the  milder  grades  of  mania  should  not  be  treated 
in  the  family,  because  the  necessary  removal  of  external 
irritants  is  there  impossible,  and  the  patient  cannot  be 
kept  constantly  in  bed.  This  is  often  attainable  in  a  hos- 
pital. When  the  motor  excitement  is  pronounced,  an  asy- 
lum is  the  only  proper  place  for  treatment.  The  possi- 
bility of  isolation  is  especially  important,  because  when 
employed  in  moderation,  especially  in  combination  with 
frequent  attempts  to  bring  the  patient  again  among  others 
and  thus  to  give  him  opportunity  for  occupation,  isola- 
tion is  the  most  important  aid  against  maniacal  excite- 
ment. We  can  generally  dispense  with  mechanical  re- 
straint, or  at  least  get  along  with  the  milder  measures, 
such  as  the  application  of  leather  gloves.  Permanent  re- 
straint is  only  justifiable  in  cases  of  severe  surgical  in- 
juries and  threatening  exhaustion  of  the  vital  powers.  A 
well-fitted  asylum  is  provided  with  gardens  in  which  ex- 
cited patients  may  walk  undisturbed  for  a  few  hoars 
every  day.  It  is  still  better  when  the  excitement  can  be 
calmed  by  suitable  occupation.  In  milder  grades  the 
maniac  often  expends  his  excitement  in  garden  and  field 
work,  and  such  occupations,  together  with  walks  in  the 
open  air,  cannot  be  recommended  too  highly. 

Prolonged  baths  are  useful  for  sedation,  and  frequent 
baths  are  also  necessary  for  the  care  of  the  skin.  The 
room  should  be  well  warmed,  the  clothing  should  be 
warm,  SDugly  fitting,  and  occasionally  closed  on  the  back 
by  special  mechanical  contrivances.  Food  must  be  fre- 
quently offered  if  the  patient  forgets  to  eat  and  drink  on 
account  of  the  excitement. 

Among  the  hypnotics,  choral  hydrate  with  the  addition 
of  morphine  is  very  effective ;  sulf onal  may  sometimes  be 
given  unnoticed.  The  greater  the  excitement  the  more 
important  do  hypodermic  injections  of  morphine  become. 
They  are  especially  useful  in  disquieting  hallucinations, 
particularly  when  repeated  methodically.  In  the  milder 
grades  of  mania,  when  there  is  a  sexual  color  to  the  symp- 
toms, and  in  the  protracted  forms,  sedation  often  follows 


216  HANDBOOK   OF   INSANITY. 

the  use  of  potassium  bromide  in  large  doses.  Abstrac- 
tion of  blood  is  only  permissible  in  symptoms  of  meningitic 
or  protracted  cortical  irritation.  Even  then,  the  results 
are  only  temporary.  Ansenria  indicates  the  administra- 
tion of  suitable  remedies,  but  the  chief  importance  at- 
taches to  good  nutrition.  Strong  cathartics  should  be 
avoided  and  a  movement  from  the  bowels  every  second  or 
third  day  will  suffice. 

The  methodical  use  of  hypnotics  often  will  secure  per- 
manent rest  in  bed,  but  we  must  avoid  excessive  doses  in 
recent  cases,  because  termination  in  dementia  is  not  infre- 
quent. 

The  psychical  treatment  of  mania  cannot  be  laid  down 
in  general  rules,  and  requires  an  inborn  talent  more  than 
in  other  psychoses.  Inappropriate  commands  and,  to  still  a 
greater  extent,  anger  concerning  foolish  acts  on  the  part 
of  the  patient  are  injurious.  A  jest  at  the  proper  time 
will  sometimes  prevent  an  outbreak  of  anger.  As  a 
matter  of  course,  such  ruses  are  useless  in  violent  mania. 

As  a  general  thing  it  it  is  advisable  to  delay  removal 
from  the  asylum  until  recovery  is  complete.  At  all  events 
travel  and  other  distractions  are  injurious  during  conva- 
lescence. If  such  convalescents  come  under  the  care  of 
the  general  practitioner,  he  must  continue  to  keep  awaj* 
all  external  irritants  and,  when  necessary,  secure  com- 
plete quiet  by  the  use  of  morphine.  Under  such  circum- 
stances it  is  an  excellent  remedy  when  given  internally. 

C.    PERIODICAL  FORMS. 

Almost  all  psychoses  exhibit  periodical  changes  in  their 
course,  especially  during  their  development.  These 
changes  are  usually  irregular  and  due  to  accidental  exter- 
nal causes.  In  discussing  melancholia  and  mania,  it  was 
found  that  the  changes  of  reaction  in  the  mood  were  much 
more  distinct  when  the  mental  constitution  had  been  im- 
paired, prior  to  the  attack,  by  hereditary  taint  or  acquired 
disability.     The  influence  of  heredity  is  visible  in  a  large 


PERIODICITY   OF   SYMPTOMS.  217 

number  of  mental  disorders.  Certain  groups  are  distin- 
guished as  periodical  forms  of  insanity,  because  period- 
icity is  their  most  important  clinical  sign.  In  addition, 
we  find  that  the  development  and  decline  of  the  disease  are 
comparatively  rapid.  The  morbid  condition  itself  is  very 
variable  and  mingled  with  healthy  elements.  In  the  in- 
tervals between  the  attacks  the  patients  are  not  normal, 
and  a  new  attack  may  develop  from  the  internal  predis- 
position, without  external  influences.  As  a  matter  of 
course,  all  exciting  causes  may  interfere  with  the  regular 
periodical  course.  When  distinct  attacks  recur  at  long 
irregular  intervals,  the  difference  between  this  invalid 
basis  and  completely  restored  mental  health  after  a  psy- 
chosis affecting  a  healthy  brain  is  shown  in  various  ways. 
Such  persons  are  easily  exhausted,  sensitive,  and  irritable. 
On  the  other  hand,  there  is  a  certain  apathy  to  higher  in- 
terests or  such  interest  is  associated  with  stress  upon  the 
personal  relations.  Great  facility  in  the  association  of 
ideas  may  permit  bold  series  of  thoughts,  but  they  cannot 
be  worked  out  with  patience.  If  no  independence  of  reso- 
lution is  required,  such  an  individual  may  long  conceal  his 
morbid  impulses  under  the  influence  of  an  habitual  activity 
which  is  regulated  by  others.  In  conversation,  however, 
we  can  detect  peculiar  turns  of  thought,  and  the  entire 
behavior  is  out  of  the  common  run. 

In  view  of  the  fact  that  these  individuals  are  not  men- 
tally healthy,  we  must  regard  complete  psychoses,  which 
develop  in  them,  as  persisting  during  life,  so  that  the 
periodical  changes  in  the  symptoms  develop  during  the 
course  of  the  disease.  A  main  difference  consists  in  the 
fact  that,  in  the  one  case,  the  changes  occur  close  together 
within  the  brief  duration  of  the  psychosis  proper,  while, 
in  the  other  case,  they  accompany  the  entire  life.  Certain 
of  these  groups  are  characterized  by  an  approximate  regu- 
larity as  regards  the  duration  and  form  of  the  symp- 
toms. Irregular  periodical  changes  are  excluded  from  the 
present  discussion;  the  diseases  which  will  now  be  de- 
scribed belong  almost  exclusively  within  the  boundaries 


218  HANDBOOK   OF   INSANITY. 

of  melancholia  and  of  mania.  They  are  composed  of  the 
regular  recurrence  of  melancholic  or  maniacal  conditions, 
or  of  the  regular  alternation  of  melancholia  and  mania. 
The  apparent  caprice  in  their  occurrence  has  only  a  clinical, 
not  an  anatomical  basis.  The  hereditary  taint  is  common 
to  the  other  irregularly  varying  psychoses,  and  the  in- 
validism of  the  entire  mental  constitution  is  found  in  cer- 
tain other  periodical  affections  associated  with  invalidism 
of  the  entire  nervous  constitution,  such  as  neurasthenic, 
epileptic,  and  hysterical  conditions.  The  latter  occupy  a 
special  position  on  account  of  the  distinct  appearance  of 
many  nervous  symptoms  which  have  an  organic  basis. 
It  is  important  to  know  that  the  first  attack  of  periodical 
insanity  is  often  due  to  an  external  exciting  cause.  Then 
in  the  following  attacks  the  definitive  clinical  history  is 
gradally  evolved  out  of  the  general  mass  of  symptoms. 

Periodical  Melancholia. 

It  occurs  more  frequently  in  private  practice  than  in 
asylums,  because  it  is  usually  mild,  and  consists  mainly 
of  the  distressing  consciousness  of  inhibited  thought  and 
volition,  or  of  inhibited  feelings.  This  restriction  is  con- 
fined mainly  to  the  course  of  ideas,  and  there  is  an  absence 
of  hallucinations ;  the  anxious  reaction  of  feeling  and  the 
depressed  mood  are  not  attempts  at  explanation,  but  are  the 
original  symptoms  of  a  true  melancholia.  Consciousness 
is  little  impaired,  but  its  contents  are  often  narrowed  by 
imperative  conceptions. 

Typical  periodical  melancholia  begins  rapidly  after  a 
brief  initial  depression.  The  pronounced  melancholia 
then  lasts  either  for  a  comparatively  short  time  (a  few 
weeks)  or  for  one  or  more  years,  the  latter  being  the  com- 
mon form.  Consciousness  is  then  clear,  and  the  memor}r 
of  events  is  subsequently  complete.  Hallucinations  are 
rare  and  usually  present  only  at  the  start.  During  the 
entire  period,  however,  certain  delusions  often  persist  un- 
changed and  are  accompanied  by  anxious  feelings  of  vary- 


REPETITIONS    OF   SYMPTOMS.  219 

ing  intensity.  The  character  of  the  ideas,  the  tendency 
to  suicide,  and  the  other  symptoms  are  the  same  as  in  ordi- 
nary melancholia.  Then,  without  any  apparent  previous 
change,  the  terror  and  delusions  are  very  often  lost  sud- 
denly. The  patient,  who  yesterday  was  very  ill,  meets  us 
to-day  with  cheerful  mien,  and  declares  himself  perfectly 
healthy.  In  fact,  physical  recovery  now  takes  place  very 
rapidly,  and  the  change  in  the  bodily  weight  is  especially 
striking. 

The  first  attack  of  a  subsequent  periodical  series  might 
be  suspected  from  the  rapid  onset  and  subsidence,  if  we 
knew  the  patient's  previous  mental  constitution.  This 
would  be  substantiated  if  the  feeling  of  illness  often  was 
accompanied  by  attempts  at  explanation,  as,  for  example, 
that  the  patient  had  committed  a  crime,  and,  in  his. opin- 
ion, was  only  disquieted  by  justifiable  remorse. 

When  the  attack  is  over,  no  mental  weakness  is  notice- 
able as  regards  the  patient's  occupation,  but  there  is  usu- 
ally a  slight  ethical  defect,  perhaps  shown  only  in  the 
prominence  of  egoistic  feelings  and  the  lack  of  sympathy 
for  others.  In  many  cases,  however,  they  are  less  inde- 
pendent and  more  irritable  when  unusual  demands  are 
made  upon  them  than  before  the  first  attack.  This  gen- 
erally occurs  in  the  twenties,  rarely  at  a  later  period.  Ten 
years  or  more,  as  a  rule,  elapse  before  the  second  attack. 
Then  a  second  attack  occurs  suddenly,  similar  in  all  details 
to  the  previous  one.  Thus,  one  patient  was  dominated, 
in  three  attacks,  by  the  delusion  that  she  had  choked  her 
mother  to  death  years  before ;  even  the  same  movements, 
refusal  to  take  food,  moaning,  and  crying  were  repeated  in 
exactly  the  same  manner. 

The  rare  brief  periodical  attacks  exhibit  a  few  devia- 
tions. The  symptoms  of  inhibition  predominate,  and 
almost  stuporous  signs  are  found.  Violent  fear  with 
occasional  outbreaks,  auditory  hallucinations,  usually  of  a 
religious  character,  sometimes  vivid  visual  and  olfactory 
hallucinations  torment  the  patient,  who  is  apparently  rigid. 
Afterward  he  proves  that  he  was  cognizant  of  things  going 


220  HANDBOOK  OF   INSANITY. 

on  about  him.  At  the  end  of  a  few  weeks  the  condition 
ceases  almost  suddenly ;  the  patient  states  that  he  feels  as 
if  a  veil  or  pressure  were  removed,  and  that  he  feels  well. 
There  is  often  refusal  to  take  food,  so  that  the  weight  of 
the  body  may  diminish  very  markedly  in  a  few  weeks. 
Then  follows  the  free  period,  usually  lasting  several 
months,  rarely  more  than  a  year,  as  in  one  patient  under 
my  observation.  At  first  his  attacks  were  very  much 
alike,  but  then  the  intervals  became  shorter  and  to  the 
former  symptoms  of  pure  melancholia  were  added  delu- 
sions that  had  not  been  noticed  before,  associated  with 
auditory  hallucinations  and  fear  of  poisoning.  Finally 
he  committed  suicide.  During  the  free  intervals  he  rec- 
ognized the  morbid  nature  of  his  illness. 

The  rare  cases  of  periodical  melancholia  are  increased 
somewhat  in  number  by  a  few  cases  in  which  the  pre- 
dominant affect  is  accompanied  by  impulsive  centrally 
produced  movements ;  in  addition  there  are  numerous  hal- 
lucinations. If  the  remembrance  of  the  attack  is  very  in- 
distinct, we  must  always  think  of  the  possibility  of  an 
epileptic  dream  condition. 

As  a  rule,  the  treatment  of  a  periodical  attack  requires 
admission  to  an  asylum,  where  the  measures  to  be  adopted 
^re  the  same  as  in  every  melancholia. 

Periodical  Mania. 

Periodical  mania  is  much  more  frequent  than  periodical 
melancholia,  particularly  in  females.  It  is  sometimes 
synchronous  with  menstruation,  bat  more  frequently  this 
exerts  little  influence.  Some  observers  believe  that  the 
attacks,  even  in  males,  attend  periodical  increase  of  sexual 
desire.  Melancholic  prodromata  are  not  constant.  They 
are  often  very  slight,  but  in  severe  and  prolonged  periodical 
mania,  prodromal  severe  melancholic  symptoms  are  con- 
stant. The  milder  cases  are  more  frequent.  In  them  the 
maniacal  excitement  begins  suddenly,  remains  at  its  height 
for  several  weeks,  and  then  subsides  with  equal  abruptness. 


PERIODICAL   MANIA.  221 

At  the  height  of  the  disease  the  mixture  of  healthy  and 
morbid  elements  is  especially  distinct,  and  the  patients 
are  constantly  attempting  to  justify  their  irrational  speech 
and  acts  in  long  harangues.  If  the  necessary  dialectic 
skill  is  wanting,  it  is  replaced  by  brief  remarks,  such  as 
"  that  it  is  natural  to  get  violent  and  excited,  if  one  is  con- 
stantly irritated,"  etc.  Hence,  these  milder  cases  often 
create  the  impression  of  moral  depravity  because  the  im- 
pulse to  movement  and  the  inner  restlessness  constantly 
give  rise  to  deeds  which  are  contrary  to  morals.  The 
perfectly  proper  behavior  after  the  attack  shows  the  mor- 
bid basis  of  the  former  condition  so  much  more  distinctly. 
In  the  quiet  intervals  the  patients  are  usually  silent  con- 
cerning the  excited  stage,  and  answer  evasively,  or  attri- 
bute it  to  supposed  irritation  in  the  surroundings.  The- 
intervals  rarely  last  more  than  a  few  weeks  or  months. 
These  mild  attacks  often  recur  during  the  patient's  entire 
life,  without  any  external  provocation.  The  patients 
always  exhibit  distinct  evidences  of  mental  invalidism; 
in  the  intervals  they  are  irritable  and  often  apathetic  to 
outside  interests.  With  advancing  years  the  boundaries 
of  the  attacks  may  be  somewhat  obliterated  and  the  excite- 
ment grows  less ;  there  is  distinct  diminution  of  mental 
ability,  but  dementia  does  not  develop. 

In  another  series  of  cases  the  flight  of  ideas  is  more 
pronounced  during  the  attack;  insomnia,  motor  restless- 
ness, and  hallucinations  occur  in  the  same  way  as  in  a 
single  attack  of  violent  mania.  The  combination  with 
angry  passions  is  verjr  common.  But  even  in  the  highest 
grades  of  excitement  the  patient  very  often  remains  ra- 
tional, in  a  way,  and  the  profound  disturbances  of  con- 
sciousness with  subsequent  amnesia,  which  occur  in  the 
severest  grades  of  mania,  are  very  rare.  The  mixture  of 
healthy  and  morbid  elements  is  likewise  characteristic  of 
this  form  of  disease.  As  a  rule,  the  severe  forms  of  peri- 
odical mania  also  develop  and  subside  more  rapidly  than 
single  attacks,  but  diagnostic  doubt  can  only  be  removed 
after  the  repetition  of  the  attack.     The  similarity  between 


222  HANDBOOK   OF   INSANITY. 

the  different  attacks  has  even  been  spoken  of  as  photo- 
graphic. In  some  cases  there  is  an  exact  repetition  of  va- 
rious physical  signs  (vasomotor  paralyses,  unilateral  head- 
ache, increased  secretion  of  urine  or  perspiration,  etc.) 
and  even  the  tone  of  the  voice,  the  facial  expression,  the 
dancing  and  jumping  are  repeated  in  exactly  the  same 
manner. 

The  same  delusions  and  hallucinations  with  very  simi- 
lar contents  also  make  their  appearance.  In  an  asylum, 
in  which  the  outbreak  of  the  new  attack  is  not  obliterated 
by  external  influences,  slight  changes  in  clothing  or  the 
constantly  repeated  desire  for  their  discharge,  usually  in- 
dicate the  beginning  of  an  attack  with  such  certainty  that 
the  attendant  is  accustomed  to  report  that  "  so  and  so  is 
about  to  have  another  attack  because  he  again  does  this  or 
that." 

The  duration  of  each  attack  is  approximately  the  same 
in  the  same  individual,  but  this  is  not  true  of  the  inter- 
paroxysmal  periods.  In  the  severe  cases  a  certain  degree 
of  mental  weakness  develops,  in  the  intervals,  with  ad- 
vancing years. 

The  prognosis  as  regards  complete  recovery  is  unfa- 
vorable, but  the  individual  attack  will  very  probably  run 
a  favorable  course  without  passing  into  a  chronic  form. 
In  the  most  favorable  cases  the  attacks  remain  absent  for 
years.     The  termination  in  dementia  is  very  rare. 

The  treatment  must  be  confined  to  the  individual  at- 
tacks. It  sometimes  appears  as  if  attempts  to  abort  an 
attack  result  in  severer  outbreaks  at  a  later  period.  Mor- 
phine and  potassium  bromide  are  chiefly  recommended, 
and  are  undoubtedly  useful  in  moderate  cases.  If  potas- 
sium bromide  is  given  in  large  doses  for  a  few  days  before 
the  threatening  outbreak  (beginning  with  6.0  gm.  daily 
and  increasing  by  2.0  gm.  daily  until  12-14.0  are  reached) 
the  prodromata  alone  may  be  developed,  and  at  all  events 
the  excited  stage,  if  it  does  appear,  is  much  milder, 
although  it  is  very  often  decidedly  prolonged.  In  some 
cases  there  was  no  doubt  that  the  duration  of  the  free  in- 


EFFECT   OF   BROMIDES.  223 

tervals  was  diminished  so  that  the  value  of  the  drug  was 
problematical.  One  patient  presented  tottering  gait  and 
thick  speech  after  large  doses  of  the  bromide,  but  during  the 
free  interval  she  begged  that  the  drug  be  given  to  her 
during  an  attack,  because  she  felt  that  the  excitement  was 
lessened  thereby,  and  it  was  then  unnecessary  to  isolate 
her. 

Even  during  the  periods  of  excitement  the  bromide  may 
be  continued,  although  in  smaller  doses.  In  one  case 
which  formerly  ran  its  course,  without  bromide,  as  an 
angry  mania  without  hallucinations,  the  attacks  after  the 
administration  of  the  drug  became  much  shorter  and 
were  attended  with  numerous  terrifying  hallucinations  of 
sight,  hearing,  and  smell,  which  resembled  so-called  hallu- 
cinatory confusion.  This  peculiar  chemical  reaction  of  the 
brain  had  no  effect  -upon  the  subsequent  free  interval. 
Then  for  a  time  bromide  was  discontinued,  and  severe  out- 
breaks were  aborted  by  sulfonal.  After  the  bromide  was 
again  administered,  there  followed  a  brief  attack,  similar 
to  the  one  described  above.  Other  observers  have  re- 
ported more  favorable  results  from  the  use  of  the  bromides. 
Periodical  manias  rarely  are  treated  at  home.  In  asylums 
their  violence  is  greatly  ameliorated  by  isolation,  and 
sometimes  this  is  effected  in  a  simple  manner  by  pro- 
tracted rest  in  bed.  Periodical  manias  are  probably  the 
most  suitable  field  for  the  application  of  methodical 
chemical  restraint,  but  even  here  narcotics  are  not  cura- 
tive remedies.  Cannabis  indica  is  particularly  praised  in 
this  condition.  In  other  respects  the  treatment  is  the 
same  as  that  of  ordinary  mania. 

Circular  Insanity. 

Those  cases  of  periodical  mania  in  which  there  is  a  pro- 
longed and  distinct  melancholic  prodromal  stage,  approxi- 
mate circular  insanity.  The  latter  consists  essentially  of 
an  alternation  of  the  maniacal  and  melancholic  conditions, 
which  either  follow  one  another  immediately  or  are  sepa- 
rated by  an  interval.     If  a  sharper  distinction  is  to  be 


224  HANDBOOK   OF   INSANITY. 

made  from  the  above-mentioned  form  of  periodical  mania, 
then  circular  insanity  must  be  regarded  as  dependent  upon 
the  existence  of  a  perfectly  free  interval  and  not  merely 
of  the  apparent  quiet  of  a  transition.  In  the  sequence  of 
mania  and  melancholia  the  occurrence  of  a  free  interval 
would  be  of  less  diagnostic  importance  because  this 
sequence  occurs  only  in  circular  insanity.  Conditions  of 
exhaustion  with  a  tinge  of  melancholy  are  comparatively 
rare  after  mania.  As  a  matter  of  fact,  every  possible 
form  of  combination  between  melancholia,  mania,  and 
free  intervals  is  observed.  Cases  in  which  a  free  interval 
does  not  develop  between  the  two  antagonistic  conditions 
are  called  alternating  insanity;  but  the  generic  term, 
circular  insanity,  also  applies  to  them. 

Special  attention  must  be  paid  to  the  distinction  be- 
tween a  true  and  an  apparent  interval.  We  will  suppose  a 
patient  in  the  period  of  maniacal  excitement ;  after  the  ex- 
citement has  reached  its  height  it  begins  to  diminish. 
He  becomes  less  violent  in  his  speech  and  acts,  but  his 
former  personality  has  not  returned.  He  sees  everything 
in  a  bright  light,  makes  all  sorts  of  plans,  interferes  in 
matters  which  do  not  concern  him.  It  is  evident  to  every 
unbiassed  observer  that  he  is  not  yet  well.  Then  the 
excitement  diminishes  still  further.  A  condition  of  rest 
and  external  equilibrium  follows,  but  is  very  brief.  The 
first  signs  of  returning  trouble  appear,  the  patient  seeks 
solitude,  and  soon  the  melancholic  condition  is  distinct. 

Now  let  us  consider  a  true  interval.  A  patient  is  in 
the  period  of  melancholic  depression  but  has  begun  to 
resume  his  accustomed  occupations.  He  begins  to  regard 
himself  as  well,  and  judges  correctly  his  previous  morbid 
and  his  present  condition.  His  complete  personality  is 
restored.  The  longer  this  condition  lasts  (and  it  may 
last  several  months  or  more)  the  more  distinctly  is  it  a 
true  interval.  This  interpretation  is  not  changed,  even 
if  the  former  personality  exhibited  the  signs  of  mental  in- 
validism, because  this  is  generally  the  case  in  circular 
insanity. 


APPARENT   ECCENTRICITY.  225 

We  will  now  give  the  clinical  history  of  true  circular 
insanity,  with  or  without  intervals,  devoting  our  atten- 
tion first  to  the  milder  forms  because  they  are  more  fre- 
quent and  come  under  the  notice  of  the  general  practitioner. 
We  often  meet  with  individuals  who  are  not  regarded  as 
insane,  but  who  pass  their  entire  lives  in  a  periodical  alter- 
nation of  moderate  excitement  and  depression.  In  the 
excited  period  they  appear  to  exhibit  merely  a  slight 
change  of  character  and  at  times  an  unusual  activity. 
They  pay  numerous  visits,  write  unnecessary  letters  to 
mere  acquaintances,  sleep  little,  make  trips,  are  exces- 
sively cheerful  on  every  occasion.  Although  their  acts 
are  done  in  a  disorderly  way  and  their  conversation  ex- 
hibits something  of  an  incoherent  character,  their  real 
condition  is  not  noticed  by  persons  who  have  not  known 
them  at  an  earlier  period,  although  its  morbid  character 
will  not  escape  the  careful  observer  and  is  sometimes  even 
diagnosed  correctly  by  members  of  the  family. 

This  morbid  condition  becomes  more  distinct  when, 
after  the  excitement  has  lasted  a  longer  or  shorter  time, 
it  passes  gradually  or  suddenly  into  the  opposite  condition, 
so  that  we  seem  to  be  dealing  with  two  different  individ- 
uals. The  patient  ceases  to  make  visits,  becomes  reticent, 
seeks  solitude,  complains  of  general  malaise,  precordial 
fear,  and  loss  of  appetite ;  he  is  sad  and  anxious  without 
reason.  He  has  a  distinct  feeling  of  his  condition  and  is 
depressed  on  that  account.  This  may  lead  to  refusal  to 
take  food,  and,  in  extreme  grades,  he  locks  himself  in  his 
room  for  several  months,  without  attracting  notable  atten- 
tion on  the  part  of  those  around  him.  Other  individuals 
see  him  only  from  time  to  time  and  have  no  opportunity 
of  observing  him  while  he  is  locked  in  his  room.  Hence 
they  have  no  suspicion  with  regard  to  his  peculiar  condi- 
tion for  a  number  of  months,  and  when  he  again  makes 
his  appearance — when  the  period  of  excitement  again  be- 
gins— he  appears  to  be  the  same  person  as  before.  He 
may  be  regarded  as  an  eccentric  character,  of  feverish 
activity,  but  his  morbid  condition  can  only  be  determined 
15 


226  HANDBOOK   OF   INSANITY. 

by  accurate  observation  of  the  alternation  between  excite- 
ment and  depression. 

This  mild  grade  of  circular  insanity  runs  its  course 
almost  unnoticed,  and  yet  it  alone  serves  to  explain  the 
peculiarities  of  certain  individuals.  In  many  of  these 
cases  the  first  indications  are  observed  in  childhood.  For 
long  periods  such  children  exhibit  unfounded  depression 
and  excessive  riotousness,  which  is  attributed  generally  to 
moral  defects  or  improper  education.  Years  elapse  before 
the  distinct  development  of  the  disease.  Circular  insanity 
may  be  regarded  as  an  intensification  of  the  change  of 
mood  which  occurs  with  a  sort  of  regularity  and  without  ex- 
ternal cause  in  individuals  with  an  hereditary  taint.  This 
interpretation  is  not  shaken  by  the  fact  that  outbreaks 
of  the  disease  occur  chiefly  in  the  developmental  years 
and  at  the  extinction  of  sexual  activity.  For  this  reason 
the  larger  proportion  of  patients  belongs  to  the  female 
sex. 

Although  there  are  many  transitions  between  this  half 
concealed  form  and  the  distinct  circular  forms,  we  will 
now  consider  only  one  in  which  all  the  symptoms  are  fully 
developed.  It  may  begin  suddenly  or  very  slowly,  but 
the  circle  usually  begins  in  the  same  way  in  the  same  pa- 
tient. The  circular  course  is  rarely  distinct  from  the  start, 
and  its  development  is  often  preceded  for  years  by  fre- 
quent attacks  of  single  or  periodical  melancholia  or  mania. 
The  variability  of  the  psychoses  which  are  based  on  an 
hereditary  taint  appears  to  require  a  certain  length  of  time 
before  definitive  conditions  develop. 

Let  us  assume  a  case  in  which  a  severe  melancholic 
condition  has  developed  rapidly  after  an  apparent  or  real 
interval.  In  order  to  give  all  the  different  possibilities, 
we  would  have  to  describe  again  the  symptoms  of  melan- 
cholia in  general.  It  will  be  sufficient  to  emphasize  a  few 
symptoms.  A  striking  phenomenon  is  the  distinct  mimic 
expression,  and  we  are  justified  in  attributing  this  to  the 
fact  that,  as  a  rule,  the  most  profound  disturbance  of  con- 
sciousness does  not  occur  in  the  melancholic  stage  of  cir- 


STUPOR.  227 

cular  insanity.  The  feeling  of  illness  is  generally  very 
pronounced,  and  makes  the  patient  extremely  unhappy; 
when  he  is  still  communicative,  he  often  expresses  great 
fear  of  the  oncoming  attack  of  excitement  which  he  fore- 
sees. Definite  delusions  are  rarely  observed.  In  more 
marked  stupor  the  face  assumes  a  mask-like  expression, 
and  changes  of  expression  are  accomplished  by  slow  con- 
tractions of  the  muscles.  Furrows  and  wrinkles  are  lit- 
erally graven  into  the  skin.  More  rarely  the  expression 
of  spiritual  pain  is  associated  with  that  of  purely  physical 
headache;  then  we  probably  find  rush  of  blood  to  the 
head,  ringing  in  the  ears,  a  feeling  of  pressure  in  the 
head.  Sleep  is  poor,  despite  the  apparent  rest  while  in 
bed;  bad  dreams. torment  the  patient.  The  weight  of  the 
body  falls  considerably,  but  after  a  time  the  body  becomes 
accustomed,  in  a  measure,  to  the  morbid  condition,  and 
there  is  a  slow  increase  in  weight. 

Let  us  now  assume  the  special  case  of  a  female  patient 
who  lies  in  bed  in  rigid  stupor.  The  condition  lasts  sev- 
eral weeks ;  the  menstruation,  which  was  due  at  this  time, 
may  remain  absent  or  it  may  have  no  effect  upon  the  con- 
dition; more  rarely  it  produces  a  change.  On  careful 
observation  slight  bodily  changes  are  found  to  appear. 
Sometimes  the  patient  takes  a  deep  breath,  lies  upon  the 
other  side  of  the  body,  the  lips  move  occasionally,  and  a 
strange  expression  flashes  across  the  face.  At  the  end 
of  a  few  hours  she  raises  herself  in  bed  and  sighs ;  the 
pulse  is  not  accelerated,  occasionally  somewhat  fuller 
than  before.  As  the  patient  soon  lies  down  again,  a  care- 
less observer  may  believe  that  the  condition  is  the  same 
as  before.  But  the  experienced  observer  recognizes  the 
slight  forerunners  of  the  storm.  It  breaks  forth  suddenly 
in  a  night,  in  a  few  hours,  even  a  few  minutes.  Now  the 
pillows  and  bedding  begin  to  fly,  loud  scolding  opens  the 
scene,  and  a  true  maniacal  frenzy  begins.  It  is  unneces- 
sary to  describe  this  further,  but  one  important  sign  must 
be  mentioned.  In  the  majority  of  cases  consciousness  is 
comparatively  well  maintained. 


228  HANDBOOK   OF   INSANITY. 

The  peculiar  lack  of  correspondence  between  a  patient's 
consciousness  and  his  really  maniacal  actions  often  makes 
him  a  veritable  torment  to  those  around  him,  especially 
when  the  maniacal  excitement  has  somewhat  lessened. 
The  patient  is  able  to  carry  out  his  desires  with  great 
shrewdness,  and  to  make  thorough  use  of  every  opportu- 
nity in  this  direction.  Hence,  he  is  very  fertile  in  devis- 
ing measures  to  deceive  his  attendants,  to  steal  the  property 
of  others  (often  entirely  useless  articles) ,  and  to  carry  out 
all  possible  useless  follies.  In  the  asylum  he  soon  rules  his 
fellow-patients,  fleeces  them  whenever  possible.  This  is 
made  easier  by  his  conversational  talent.  Such  patients 
become  so  much  more  troublesome  because,  on  account  of 
their  constant  affirmation  of  their  clear  mind  and  fine  cul- 
ture, they  are  often  transferred  to  better  wards,  where  they 
are  a  source  of  great  annoyance  to  more  rational  patients. 
They  are  filthy  in  the  extreme  and  carry  the  dirtiest  articles 
in  their  pockets ;  they  flare  up  at  every  remonstrance,  and 
attempt,  by  means  of  loquacity,  to  conceal  their  faults  from 
others. 

A  very  characteristic  feature  during  the  excitement  is 
the  mimic  facial  expression  and  the  general  bearing,  which 
acquire  a  stereotyped  appearance  in  the  course  of  time. 
As  a  matter  of  course,  the  expression  is  not  constant  but 
changes  frequently.  But  the  repetition  of  the  same  range 
of  feelings  is  exhibited  in  every  fresh  attack  by  the  same 
gestures,  speech,  and  expression.  Occasionally  there  is  a 
temporary  tearful  affect,  more  rarely  a  true  melancholic 
depression  of  brief  duration. 

The  attack  almost  always  subsides  slowly.  Opinions 
differ  as  to  whether  the  circle  begins  with  melancholia  or 
mania.  The  majority  are  agreed  that  melancholia  opens 
the  scene,  so  that  we  are  perhaps  justified  in  assuming 
that  the  melancholic  stage  has  been  overlooked  in  the  other 
mild  cases. 

It  has  often  been  maintained  that  circular  insanity  is 
always  unattended  with  hallucinations,  but  this  is  not 
always  true.     Perhaps  they  appear  only  in  the  severest. 


HANDBOOK  OF  INSANITY. 

KIRCHHOFF. 


Plate  III. 


:_._J 


DESCRIPTION  OF  PLATE  III. 

PERIODICAL    FORMS. 

The  rare  form  of  periodical  melancholia  generally  presents  no 
changes  in  expression  from  that  found  in  simple  melancholia.  The 
two  upper  pictures  represent  an  impure  form  of  periodical  melan- 
cholia, because  it  is  irregularly  interrupted  by  conditions  of  violent 
excitement ;  on  the  whole,  however,  the  periodical  change  is  con- 
fined to  the  melancholic  depression.  The  first  picture  illustrates, 
in  part,  the  remarks  made  concerning  the  plate  on  melancholia. 

The  second  picture  exhibits  a  peculiar  expression  which  has 
nothing  to  do  with  melancholia.  It  was  due  only  in  part  to  the 
depressed  mood  of  the  patient,  but  chiefly  to  the  bright  sunlight. 
The  wrinkling  of  the  forehead  and  eyebrows,  the  folds  on  the  skin 
of  the  nose,  the  drawing  upward  of  the  lower  lids,  cheeks,  and 
upper  lip  serve  to  diminish  the  palpebral  opening  and  prevent  the 
entrance  of  light.  The  same  play  of  features  was  repeated,  how- 
ever, in  a  darker  place,  and  the  patient's  conversation  showed  that 
she  experienced  feelings  of  disgust  and  repulsion,  associated  with 
the  melancholic  mood. 

Periodical  mania  may  run  through  the  entire  gamut  of  cheerful 
expressions,  passing  into  rage  and  the  most  immoderate  affects, 
which,  in  part,  cannot  be  photographed.  There  is  even  difficulty 
in  milder  forms  of  excitement  on  account  of  the  bodily  move- 
ments. For  example,  in  the  first  of  the  two  lower  pictures  the 
woman  seats  herself  in  order  to  be  photographed  ;  hence  the  bold 
draping  of  the  shawl  and  the  comfortable  position  of  the  hands. 
The  firmly  closed  mouth,  together  with  the  lightly  wrinkled  eye- 
brows, which  are  drawn  downward,  give  an  expression  of  decision 
with  a  slight  admixture  of  mocking  spite  resulting  from  the  slight 
elevation  of  the  mouth  on  one  side,  where  the  naso-labial  fold  is 
more  distinct. 

The  second  picture  gives  a  cheerful  and  cunning  expression, 
owing  to  the  smooth  forehead,  the  elevation  of  one  eyebrow,  and  the 
raised  angles  of  the  mouth  with  pronounced  naso-labial  folds. 


HANDBOOK  OF  INSANITY. 

KIRCHHOFF. 


Plate  IV. 


DESCRIPTION  OF  PLATE  IV. 

PERIODICAL    FORMS. 

In  circular  insanity  we  furnish  pictures  merely  of  the  antago- 
nistic maniacal  and  melancholic  conditions,  as  the  expression  in 
the  latter  is  very  similar  to  that  in  the  free  intervals. 

The  pictures  show  this  antagonism  very  distinctly.  As  the 
wrinkles  of  the  melancholic  period,  which  persist  for  a  long  time, 
are  permanently  fixed,  the  expression  of  excitement  is  somewhat 
obliterated.  Upon  the  forehead  of  the  melancholic  woman  are 
two  semicircular  furrows  above  the  outer  parts  of  the  eyebrows. 
During  the  melancholic  stage  this  patient  suffered  from  violent 
headache,  and  the  frontal  muscle  exhibited  frequent  brief  con- 
tractions in  its  outer  parts  above  these  furrows.  The  spasmodic 
muscular  contraction  was  confined  to  the  outer  parts  because  the 
median  portion  is  held  more  firmly  in  position,  and  hence  the 
peculiar  semicircular  furrows  were  produced. 

As  a  matter  of  course  there  was  a  very  active  play  of  features 
during  the  period  of  excitement,  and  the  pictures  can  therefore 
only  be  regarded  as  accidental  forms  of  expression.  Both  patients 
spoke  constantly  and  made  grimaces. 


TERMINATIONS.  229 

cases,  especially  when  the  change  coincides  with  the 
period  of  menstruation. 

The  duration  of  the  different  periods  varies  greatly  in 
different  individuals,  but  they  are  more  uniform  in  the 
same  patient.  In  very  rare  cases  a  period  runs  its  course 
in  a  few  days,  usually  several  weeks  elapse,  occasionally 
even  months  and  years.  In  general  the  melancholic  stage 
is  longer  than  the  maniacal  stage,  and  the  intervals  are 
shorter  than  either.  The  greatest  variability  is  shown  in 
the  duration  of  the  intervals,  which  are  so  much  more 
marked  the  more  pronounced  the  excitement  has  been. 

The  termination  in  true  dementia  is  not  observed.  The 
intelligence  remains  at  the  same  level  after  the  disease 
has  lasted  twenty  or  thirty  years  or  even  longer.  The 
patients  rarely  exhibit  premature  mental  or  physical  decay. 

As  a  general  thing  the  disease  grows  weaker  in  old  age, 
both  as  regards  the  duration  and  severity  of  the  attacks. 
If  the  intervals  are  also  shortened  and  mixed  a  form  of 
disease  may  finally  be  produced,  in  which  only  the  fre- 
quent and  rapid,  but  brief,  changes  of  mood  furnish  indi- 
cations of  the  former  course. 

The  prognosis  is  unfavorable,  and  real  recovery  is  never 
observed.  Even  temporary  amelioration  of  the  symptoms 
is  not  a  favorable  sign,  because  they  majT  soon  be  replaced 
by  more  severe  ones.  In  very  rare  cases  the  climacteric 
is  a  turning-point,  from  which  a  decided  improvement 
starts. 

Although  not  a  few  of  these  patients  suffer  in  old  age 
from  apoplectic  attacks,  no  anatomical  basis  of  the  disease 
has  been  discovered. 

We  can  merely  attempt  to  ameliorate  the  attacks  by 
means  of  treatment  and  cannot  expect  to  produce  recovery. 
The  chief  indication  is  the  removal  of  external  injurious 
influences,  and  this  can  best  be  done  in  an  asylum.  It  is 
true  that  the  asylum  authorities  are  not  inclined  to  retain 
these  patients,  especially  the  milder  cases,  because  they 
are  very  troublesome,  but  the  family  suffers  extremely 
and  the  patients  themselves  pass  through  an  attack  more 


230  HANDBOOK   OF   INSANITY. 

easily  in  an  asylum.  When  the  free  intervals  are  pro- 
longed, they  may  be  utilized  for  temporary  dismissal  from 
the  institution. 

Drugs  are  most  effective  in  hastening  the  subsidence  of 
excitement,  while  they  effect  little  in  the  beginning  of  the 
melancholic  and  maniacal  stages.  Potassium  bromide, 
as  well  as  opium  and  morphine,  are  useless.  The  treat- 
ment must  be  conducted  according  to  the  general  princi- 
ples which  have  already  been  discussed  in  various  places. 
Good  effects  are  sometimes  obtained  from  keeping  the 
patient  constantly  in  bed. 

D.    PARANOIA. 

In  the  groups  of  mental  disorders  which  are  grouped 
under  the  term  paranoia,  the  most  important  sign — apart 
from  the  symptoms  of  melancholia  and  mania  which  may 
recur  in  it — is  the  systematization  of  delusions.  In  mel- 
ancholia and  mania  the  delusions  have  somewhat  of  a 
fleeting  character,  and  the  association  of  the  concepts  is 
not  arranged  according  to  a  definite  plan.  This  takes 
place  in  paranoia.  The  manifold  combination  of  the  other 
symptoms  of  mental  disorder  with  the  so-called  fixed  ideas 
gives  rise  to  numerous  clinical  pictures.  There  is  still  a 
great  lack  of  harmony  concerning  their  classification,  but 
certain  sub-groups  are  readily  distinguished.  These  are 
"  wahnsinn"  and  "  verruecktheit."  *  Then  follows  a  third 
group  in  which  certain  terminal  states,  on  the  one  hand  of 
melancholia  and  mania,  on  the  other  hand  of  wahnsinn 
and  verruecktheit,  coincide,  but  whose  clinical  pictures 
contain  no  signs  which  point  to  the  different  origins.  In 
this  latter  group  the  term  paranoia  possesses  only  a  sec- 
ondary significance,  and  in  it  must  also  be  included  the 
terminal  forms  of  certain  conditions  which  were  recog- 
nizable originally  as  verruecktheit,  because  they,  with  all 
others,  have  the  common  feature  of  confusion,  without 
passing  into  complete  mental  imbecility  or  dementia. 

*  These  terms  have  no  exact  equivalent  in  English.  They  corre- 
spond, in  the  main,  to  what  was  formerly  called  monomania. 


WAHNSINN.  231 

1.    Wahnsinn. 

"  Wahnsinn "  is  a  mental  disorder  in  which  delusions 
and  hallucinations  are  rapidly  combined  into  a  composite 
whole,  intimately  associated  with  strong  affects.  In  ver- 
ruecktheit  the  affects  are  only  accidental  elements  of  the 
clinical  history  and  disappear  rapidly.  During  completely 
developed  wahnsinn  the  affects  are  constantly  present  as 
soon  as  the  delusions  make  their  appearance.  Hence  it  ex- 
hibits irregular  changes  in  its  appearance  which  are  absent 
to  such  a  marked  extent  in  verruecktheit.  It  is  a  more  acute 
form  of  paranoia  which,  on  the  whole,  runs  a  more  rapid 
course  and  may  offer  more  favorable  prospects  of  recovery. 
When  paranoia  occurs  in  persons  with  a  healthy  brain  it, 
appears  more  frequently  as  wahnsinn,  while  verruecktheit 
rouses  the  suspicion  of  previous  mental  invalidism. 

As  a  matter  of  course  the  description  must  distinguish 
between  the  occurrence  of  depressed  and  excited  affects, 
although  this  separation  is  often  wanting  in  the  individual 
case.  The  development  of  wahnsinn  with  depressed  affect 
has  great  similarity  to  melancholia,  but  the  significance 
of  the  delusions  is  greater,  even  at  the  beginning  of  the 
disease.  They  refer  in  a  definite  manner  to  the  patient's 
person  and  often  to  conditions  of  his  own  body.  The  rela- 
tions to  society  are  then  drawn  very  rapidly  into  the  circle 
of  these  delusions  and  are  brought  into  relation  to  anxious 
feelings  and  sensations. 

We  will  describe  the  more  violent  symptoms  of  such 
cases.  After  several  weeks  of  insomnia  and  irritable 
mood,  in  which  the  patients  draw  surprising  and  disqui- 
eting conclusions  from  harmless  perceptions,  and  concern- 
ing whose  falsity  they  do  not  allow  themselves  to  be  con- 
vinced, a  general  restlessness  makes  its  appearance, 
attended  with  considerable  disturbance  of  consciousness. 
No  connection  between  the  anxious  concepts  can  yet  be 
recognized  in  the  confused  remarks.  But  in  a  few  days 
greater  outward  calm  is  manifested,  and  we  can  obtain 
correct  information  from  the  patient  concerning  certain 


232  HANDBOOK   OF   INSANITY. 

things.  Anxious  notions  link  themselves  to  the  still  in- 
definite hallucinations,  such  as  tapping  at  the  window, 
distant  noises,  or  there  may  be  definite  shapes  and  voices. 
But  the  feeling  of  derogation,  of  persecution  by  enemies 
forces  itself  rapidly  into  the  foreground  of  his  notions; 
around  this  fixed  idea  many  others  shoot  up,  all  taking 
their  material  from  the  contents  of  consciousness,  so  that 
a  composite  whole  is  again  formed.  The  excited  anxious 
mood  does  not  permit  the  formation  of  such  a  finely  sys- 
tematized plan  as  in  verruecktheit,  but  all  thoughts  run 
together  to  one  point.  A  living  personality  remains  the 
central  point  of  the  morbid  mental  life ;  fear  captures  all 
delusions  and  does  not  permit  their  development  into  a 
firm  structure  in  such  a  quiet  reasoning  way  as  in  ver- 
ruecktheit, but  it  does  not  prevent  the  selection  and  com- 
bination of  individual  notions  according  to  a  continuous 
thread ;  the  melancholic  patient,  on  the  other  hand,  simply 
abandons  himself  to  his  anxious  notions  as  a  guilty 
sacrifice. 

Although  the  presence  of  hallucinations  cannot  be  dem- 
onstrated in  all  cases,  this  is  often  possible,  and  hence,  in 
view  of  the  similarity  of  the  other  manifestations,  their 
constant  occurrence  is  very  probable.  All  these  part-phe- 
nomena of  the  disease  add  to  the  peculiar  contents  of  the 
delusions;  their  intimate  combination  also  entails  the 
falsification  of  the  patient's  perceptions.  His  relatives 
appear  strange;  they  only  retain  their  apparent  loving 
conduct  in  order  to  conceal  their  hatred  and  evil  designs. 
Their  conduct  is  outrageous  because  he,  the  patient,  has 
done  nothing  wrong.  This  undeserved  misfortune  is  an 
undeniable  fact ;  not  alone  his  family  persecutes  him,  but 
on  the  street  every  one  looks  at  him.  In  the  asylum  the 
patients,  attendants,  and  physicians  unite  in  saying 
vulgar  things,  in  satirical  remarks  and  curses  (which  are 
based  on  hallucinations) .  The  element  of  feeling  in  the 
struggle  against  such  influences  is  especially  distinct  in 
females.  Not  alone  at  the  beginning  of  puberty,  but  also 
at  other  periods  of  life,  women  exhibit  a  violent  feeling 


DELUSIONS   OF   PEKSECUTION.  233 

with  regard  to  the  noxious  influences.  Their  fear  is  not 
a  passive  one,  which  yields  to  fate,  nor  does  it  suddenly 
lead  to  violence,  but  it  is  accompanied  by  feelings  of  pain- 
ful, unjustified  suffering  and  by  the  tendency  to  permanent 
resistance  and  struggle.  These  patients  are  apt  to  become 
violent  because  all  influences  revolve  around  their  own 
person.  They  are  always  right  and  do  not  listen  to  any 
explanation  of  falsely  interpreted  remarks  and  noises,  etc. 
(as  is  done  in  verruecktheit) ,  but  they  speak  and  gesticu- 
late constantly,  and  often  compel  us  to  restrain  them. 
This  is  naturally  a  new  proof  to  their  minds,  and  demon- 
strates the  brutality  of  their  assumed  persecutors.  The 
highest  grades  of  fear  and  terrified  resistance  are  mani- 
fested, and  such  an  anxious  excited  mood,  accompanied 
by  definite,  systematized  delusions  and  hallucinations, 
may  last  for  weeks,  months,  or  years,  with  brief  interrup- 
tions. The  latter  are  not  periods  of  exhaustion,  as  in  an 
anxious  excited  melancholia,  but  are  periodical  changes 
whose  nature  cannot  always  be  ascertained.  It  is  a  very 
important  fact  in  the  consideration  of  wahnsinn  that  sleep 
and  appetite  remain  normal.  The  good  sleep  is  an  impor- 
tant sign  in  several  respects.  It  is  unfavorable  because, 
in  doubtful  cases,  it  indicates  that  firm  delusions  are  pres- 
ent, and  hence  the  mental  disorder  offers  less  chance  of 
recovery.  The  complete  rest  of  the  body  during  sleep 
permits  irritative  conditions  in  the  internal  organs  to 
moderate,  and  the  nutrition  of  the  body  remains  good, 
but  the  patient  awakes  in  the  morning  with  the  same 
painfully  excited  demeanor  and  is  tortured  by  the  same 
ideas  of  persecution.  Hence  he  talks  a  good  deal  during 
the  day,  curses  and  threatens.  In  other  respects  his  man- 
ner is  rational.  His  clothes  are  carefully  handled,  he  is 
cleanly  and  acts  properly  at  the  table ;  indeed,  the  move- 
ments are  rarely  involuntary,  but  are  held  in  check.  The 
patient  occasionally  threatens  suicide  but  rarely  carries 
out  his  threat;  affects  are  present,  but  they  can  be  re- 
strained. On  special  occasions  in  an  asylum,  such  as 
social  festivities,  he  may  control  himself  sufficiently  to 


234  HANDBOOK    OF   INSANITY. 

take  part,  but  soon  afterward  he  again  abandons  himself 
to  his  delusions,  which  receive  a  new  impetus  from  corre- 
sponding hallucinations.  We  may  also  find  in  the  course 
of  the  disease  periods  of  external  calm  which  remind  us 
occasionally  of  a  periodical  course,  but  the  delusions  re- 
main distinct  and  thus  distinguish  the  condition  from 
periodical  insanity. 

Permanent  delusions,  which  are  associated  with  violent 
affect,  and  usually  with  an  exalted  feeling,  are  chiefly 
religious,  especially  as  they  are  almost  always  nourished 
by  hallucinations.  Here  we  find  the  inspired  prophets 
who  proclaim  their  divine  mission  in  a  loud  voice.  The 
affect  is  so  pronounced  that,  even  when  confined  to  his 
room,  the  patient  cannot  restrain  his  flow  of  speech.  These 
patients  are  not  so  careful  with  regard  to  their  personal 
appearance,  and  they  can  rarely  check  themselves  vol- 
untarily. Indeed,  the  highest  grades  of  ecstasy  may 
develop,  with  apparent  rigid  inhibition  of  all  movements. 
The  patient  sees  heavenly  visions,  Christ,  the  Virgin 
Mary,  who  call  upon  him  to  become  the  apostle,  pope,  or 
bride  of  Christ.  These  are  often  mingled  with  sexual 
sensations,  feelings  of  the  highest  bliss  and  delight. 
During  this  ecstasy,  which  does  not,  as  a  rule,  last  more 
than  a  few  days,  the  patient  is  almost  completely  insensible 
to  his  surroundings.  With  widely  opened  eyes  he  lies  mo- 
tionless on  the  floor  or  upon  his  knees.  After  the  gradual 
awaking  from  this  condition  there  is  usually  a  tolerably 
complete  memory  of  the  visionary  perceptions,  but  at  first 
there  is  no  recognition  of  the  diseased  element.  Their 
experiences  are  regarded  as  true  revelations  and  are  often 
amplified  by  further  similar  hallucinations.  For  some 
time  the  patient  cannot  find  his  bearings  and  occasionally 
does  all  sorts  of  queer  acts,  gesticulates,  cries  out  aloud, 
or  strips  off  his  clothing. 

In  other  cases  the  ecstasy  is  not  so  profound  and  pro- 
tracted. The  patient  is  impelled  to  preach  the  corruption 
of  the  world,  to  assert  himself  to  be  the  Saviour,  every- 
thing being  uttered  with  great  pathos.     This  condition 


TERMINATIONS.  235 

acquires  great  dramatic  power  when  the  supposed  message 
from  heaven  is  associated  with  the  notion  of  a  struggle 
against  the  powers  of  evil.  In  the  course  of  time  these 
patients  learn  to  control  themselves  somewhat,  and  for  a 
number  of  days  may  even  recognize  that  they  have  acted 
under  a  delusion. 

This  is  the  way  in  which  recovery  slowly  takes  place. 
But  a  subsidence  of  the  symptoms  must  not  rouse  inordi- 
nate hopes,  inasmuch  as  wahnsinn  is  one  of  the  less 
favorable  forms  of  insanity  and  terminates  quite  often  in 
confusion.  As  a  general  thing,  wahnsinn  with  exalted 
mood  runs  a  more  rapid  course  than  that  form  which  is 
associated  with  depression.  One  year  is  the  average 
duration  in  cases  which  recover.  In  unfavorable  cases  the 
affective  basis  does  not  then  disappear,  the  delusions  re- 
tain their  loosely  connected  systematization,  and  the  tran- 
sition into  progressive  confusion  is  gradual.  Finally  a 
certain  irritable,  silly  character  occupies  the  foreground, 
but  not  dementia.  The  terminal  stage  cannot  be  distin- 
guished from  other  disorders  which  pass  into  the  clinical 
history  of  general  paranoia. 

The  two  forms  of  wahnsinn  which  have  been  mentioned 
occur,  as  a  rule,  in  middle  life.  The  development  is  not; 
rapid.  Careful  observation  shows  a  prodromal  irritable 
stage  which  lasts  at  least  several  weeks.  As  a  matter  of 
course  the  delusions  are  much  more  manifold  than  has 
been  described  above,  but  the  various  similar  manifesta- 
tions of  this  kind  will  be  considered  under  the  heading  of 
verruecktheit. 

The  objects  of  treatment  are  sedation  and  protection.  The 
prominence  of  the  affect  requires  special  attention  because 
its  treatment  alone  offers  an  effective  weapon.  Rest  in 
bed  is  to  be  recommended;  isolation  is  advisable  when 
illusions  are  prominent,  while  true  hallucinations  become 
more  distinct  when  the  patient  is  alone.  Under  such  cir- 
cumstances the  patient  may  be  left  in  the  company  of 
others  so  long  as  he  is  not  dangerous  on  account  of  sudden 
acts.     It  is  hardly  ever  possible  to  keep  these  patients  at 


236  HANDBOOK   OP   INSANITY. 

home.  Powerful  drugs  are  necessary  to  keep  the  affects 
in  subjection,  and  the  delusions  usually  lead  the  patient  to 
refuse  drugs.  Potassium  bromide  is  the  most  valuable, 
but  only  when  given  in  large  doses.  Its  effect  may  be 
aided  by  the  use  of  morphine,  especially  in  violent  excite- 
ment. We  must  avoid  prolonged  baths,  packs,  etc.,  be- 
cause the  more  conscious  patient  sees  in  these  baths  only 
inimical  attacks ;  when  consciousness  is  more  clouded,  as 
in  the  condition  of  ecstasy,  all  these  measures  are  useless 
or  even  give  rise  to  violent  excitement. 

2.    Verruecktheit. 

"  Verruecktheit "  is  a  mental  disorder  in  which  delusions 
usually  associated  with  hallucinations  are  carefully  com- 
bined, sometimes  rapidly,  but  as  a  rule  slowly,  into  a  pro- 
gressive delusional  system ;  the  combination  with  affects 
is  accidental  and  gradually  disappears.  It  is  one  of  the 
forms  of  paranoia.  Their  relation  is  seen  particularly  in 
those  cases  which,  after  a  long  course,  terminate  in  con- 
fusion, not  in  dementia,  and  exhibit  the  same  symptoms 
that  are  found  in  the  wahnsinn,  which  terminates  in  sec- 
ondary paranoia  and  in  some  terminations  of  melancholia 
and  mania.  It  occurs  almost  exclusively  in  individuals 
with  an  hereditary  taint  and  always  runs  an  unfavorable 
course.  As  its  name  implies,  it  is  a  displacement  of  the 
mental  personality  from  its  former  position,  and  leads  to 
a  permanent  and  profound  change  in  personality.  In  the 
beginning,  at  least,  consciousness  is  unaffected,  and  the 
affects  which  are  sometimes  observed  are  only  temporary. 
As  a  rule  the  disease  develops  very  slowly ;  more  rarely  it 
apparently  begins  suddenly  after  a  short  period  of  irritable 
depression. 

Although  verruecktheit  is  not  simply  a  morbid  intensi- 
fication of  certain  peculiarities  of  character  such  as  occur 
in  persons  of  very  different  degrees  of  culture  and  stations 
in  life,  still  it  is  very  common  to  find  among  the  ancestors 
suspicious  characters  who  exhibited,  for  example,  an  unu- 


HALLUCINATORY   DELUSION   OF  PERSECUTION.      237 

sual  tendency  to  envy  or  pride.  Such  peculiarities  are 
exhibited  by  the  patient  even  during  childhood.  He  ex- 
hibited a  liking  for  solitude,  did  not  take  part  in  the  sports 
of  other  children,  and  had  no  friends  among  them.  At 
the  period  of  puberty  these  tendencies  became  more 
marked;  he  lived  secluded,  devoured  by  mistrust  and 
suspicion. 

The  great  abundance  of  forms  in  which  the  disease 
appears  necessitates  a  classification,  but  we  must  lay 
stress  upon  the  fact  that  the  following  groups  only  possess 
systematic  importance,  inasmuch  as  verruecktheit  rarely 
remains  within  the  bounds  that  will  be  set  forth. 

In  the  foreground  of  verruecktheit  stands  the  delusion. 
This  may  develop  from  so-called  primordial  delirium,  but 
is  more  often  associated  with  hallucinations.  Hence  fol- 
lows the  division  into  simple  or  hallucinatory  verrueckt- 
heit. A  further  division  refers  to  the  contents  of  the 
delusions,  which  imply  either  derogation  or  exaltation  of 
the  personality,  and  hence  the  groups  of  delusions  of  per- 
secution and  delusions  of  grandeur. 

On  account  of  its  frequency  and  the  completeness  of  its 
symptoms  we  will  first  consider  the  hallucinatory  delusion 
of  persecution. 

Its  basis  is  the  development  of  systematized  ideas  of 
derogation  as  the  result  of  permanent,  on  the  whole  mo- 
notonous hallucinations.  Strictly  speaking,  these  are  not 
fixed  ideas,  but  are,  in  a  measure,  variable  because  the 
original  delusion  acts  in  a  falsifying  manner  upon  the 
remaining  contents  of  consciousness.  Hence  a  progress 
of  the  delusions  forms  part  of  the  clinical  history.  As  we 
shall  see  later,  a  delusion  of  persecution,  for  example,  may 
develop  into  a  delusion  of  grandeur.  The  delusion  also 
extends  gradually  to  the  entire  mental  life  of  the  patient. 
The  concepts  which,  especially  at  the  onset,  were  not  yet 
morbidly  changed,  and  their  associations,  are  therefore 
only  combined  in  a  systematic  manner  in  so  far  as  they  are 
not  opposed  to  the  dominant  delusions. 

This  apparent  restriction  to  certain  circles  of  thought  is 


238  HANDBOOK   OF   INSANITY. 

at  first  so  pronounced  that  outsiders  do  not  notice  any- 
morbid  element.  Not  a  small  proportion  of  the  patients 
attend  to  their  duties  in  the  ordinary  way,  difficult  scien- 
tific labors  may  be  carried  out,  and  nothing  peculiar  is 
noticed  in  conversation.  An  occasional  smile  without 
apparent  cause,  a  peculiar  glance  toward  the  ceiling,  solil- 
oquies, etc.,  are  regarded  as  mere  peculiarities,  although 
concealed  hallucinations  and  delusions  are  already  present. 
Many  years  sometimes  pass  in  this  way.  A  slight  change 
of  manner  may  have  been  noticed  by  the  family,  but  they 
have  become  accustomed  to  it.  The  delusions  and  hallu- 
cinations often  have  not  obtained  convincing  reality  to  the 
patient,  and  their  interpretation  still  rouses  doubt.  But 
the  correct  perceptions  of  the  external  world  are  already 
combined  with  personal  sensations  and  ideas  which  falsify 
the  former;  something  that  does  not  belong  to  them  is 
looked  for  and  observed.  Startled  by  this  fact,  the  patient 
endeavors  to  quiet  himself  by  rational  reasons,  but  only 
with  temporary  success,  because  the  vivid  distinctness  of 
the  hallucinations  rapidly  overcomes  the  criticism.  This 
loss  of  criticism  is  perhaps  a  sign  of  mental  weakness ;  but 
the  judgment  of  the  patient  in  other  matters,  which  do 
not  concern  his  person,  is  still  too  great  to  permit  us  to 
regard  this  expression  as  appropriate.  The  patient  is  still 
astonished  concerning  the  awakening  mistrust  and  asks 
himself  for  the  cause.  But  he  constantly  returns  to  the 
idea  that  some  plan  has  been  formed  against  him,  that 
enemies  are  attempting  to  ruin  him.  He  now  finds  that 
everything  about  him  is  changed.  Everything  excites  his 
mistrust;  people  speak  ill  of  him  and  slander  him.  Tri- 
fling circumstances  usually  rouse  such  thoughts.  Real 
misfortunes  affect  him  less  and  are  not  attributed  to  his 
supposed  enemies,  while  slight  events  which  affect  his 
person  are  woven  into  the  developing  system  of  delusions 
of  derogation.  He  now  has  a  special  tendency  to  look 
back  into  his  past  and  to  combine  events  which  have  long 
passed  with  the  fresh  impressions  of  the  present. 

An  auditory  hallucination  of  an  inimical  character  re- 


DELUSIONAL   SYSTEM.  239 

turns  more  frequently  and  grows  louder.  More  rarely  its 
contents  are  immaterial,  but  even  then  it  is  combined  with 
the  delusional  system.  A  physical  ailment  may  effect  a 
rapid  change  in  these  concealed  processes.  In  the  large 
majority  of  cases  a  disagreeable  auditory  hallucination 
now  gives  a  definite  direction  to  the  undefined  fears.  At 
one  blow  the  concealed  contents  of  long-experienced  fears 
are  converted  into  a  terrible  certainty.  Usually  these 
hallucinations  consist  of  a  single  word  (villain,  murderer, 
pig) ,  often  they  are  a  sexual  accusation ;  or  they  are  short 
sentences  of  similar  import.  Startling  as  this  may  be  at 
first,  its  frequent  recurrence  suppresses  every  doubt  of  its 
reality,  and  it  is  often  drawn  very  slowly  into  the  con- 
stantly growing  web  of  delusions.  The  patient  hears  him- 
self mocked  everywhere,  in  the  house  and  upon  the  street. 
Now  the  links  are  formed  in  a  progressive  delusional 
system,  in  part  slowly  and  steadily  in  a  psychological 
manner,  in  part  rapidly  and  by  fits  and  starts  on  account 
of  the  morbid  irritative  condition  in  the  brain.  Usually 
he  then  infers  from  the  ever-present  danger  that  a  con- 
spiracy of  his  enemies  has  been  formed.  Wherever  he 
goes  he  finds  himself  surrounded  by  enemies  and  followed 
by  spies.  He  generally  does  not  know  his  enemies  person- 
ally, and  makes  no  further  effort  to  see  the  persons  whose 
mocking  voices  he  hears.  This  is  a  notable  evidence  of 
the  increasing  lack  of  judgment,  because  formerly  he 
would  open  the  window  or  go  to  the  street  in  order  to  see 
his  supposed  pursuers.  He  now  requires  merely  an  ex- 
planation of  the  process  and  is  apt  to  find  it  in  physical 
action  at  a  distance.  As  one  person  cannot  accompany 
him  everywhere,  he  must  be  pursued  by  a  society — Free 
Masons,  Jesuits,  secret  societies  of  all  kinds,  the  police. 
The  voices  heard  are  explained  by  electrical  apparatus  or 
the  telephone.  The  telegraph  communicates  his  fate  to 
the  entire  world.  Hence  he  refuses  to  answer  questions, 
because  the  questioner  only  pretends  to  be  ignorant  but  is 
really  cognizant  of  everything.  Soon  the  threats  are  con- 
veyed to  him  in  all  sorts  of  ways ;  any  newspaper  report 


240  HANDBOOK   OF   INSANITY. 

conveys  a  hint  of  his  crimes  and  is  worked  up  into  the 
growing  system  of  delusions.  He  finds  undeniable  accu- 
sations and  threats  everywhere ;  out  of  the  irrelevant  con- 
versation of  those  about  him  he  picks  words  and  refers 
them  to  himself.  The  people  point  at  him,  the  preacher 
refers  to  him  in  his  sermon,  and  the  street-gamins  whistle 
songs  about  him. 

A  great  feebleness  of  judgment  has  already  developed 
when  such  harmless  matters  are  drawn  without  hesita- 
tion into  the  system  of  delusions.  The  constant  observa- 
tion disquiets  the  patient  and  he  attempts  to  escape.  He 
changes  his  dwelling  or  makes  a  trip.  At  first  this  re- 
lieves him,  because  for  the  first  few  days  the  enemy 
seems  to  have  lost  track  of  him.  But  soon  the  pursuit  is 
renewed  and  the  auditory  hallucinations  again  begin. 
Again  he  changes  his  dwelling  with  the  same  result,  and 
finally  he  recognizes,  in  despair,  that  escape  is  impossible 
from  the  terrible  conspiracy  against  his  honor  or  his  life. 

Now  the  patience  of  the  persecuted  patient  may  become 
exhausted.  For  a  time  he  drops  his  timid  and  reticent 
manner  and  speaks  to  this  or  that  person  concerning 
their  inimical  conduct.  On  the  whole,  he  maintains  a 
passive  demeanor.  He  avoids  the  outer  world,  closes 
windows  and  doors,  stops  the  keyholes,  cooks  his  own 
food.  But  even  this  seclusion  is  useless  because  his 
thoughts  are  no  longer  concealed  from  his  enemies.  The 
letters  that  he  writes  are  immediately  read  aloud  by  an 
invisible  enemy ;  hardly  has  a  thought  developed  in  his 
mind  before  it  is  expressed  aloud.  Indeed,  the  current  of 
innervation  to  the  speech  muscles,  which  precedes  the 
auditory  image  in  point  of  time,  gives  rise  to  words  which 
are  spoken  before  the  thought  is  conceived.  He  is  now 
entirely  in  the  hands  of  his  enemies,  who  force  their 
thoughts  upon  him. 

The  inner  restlessness  requires  an  outlet,  and  this  is 
effected  more  frequently  by  public  accusations  than  by 
acts  of  violence.  As  a  general  thing  he  seeks  protection 
from  the  authorities.     Either  he  unfolds  the  entire  delu- 


APPEALS   TO   LEGAL   AUTHORITIES.  241 

sional  system,  and  his  insanity  is  then  evident  at  once,  or 
he  attempts  to  make  the  true  reason  of  his  persecutions 
probable  by  hinting  at  facts,  and  careful  examination  of 
all  accompanying  circumstances  may  be  necessary  before 
the  patient's  true  condition  becomes  evident.  On  the 
whole,  however,  the  authorities  pay  no  attention  to  the 
complaints,  and,  as  a  matter  of  course,  the  patient  now 
assumes  that  the  authorities  are  in  league  with  his  ene- 
mies. Higher  authorities  are  invoked ;  finally,  parliament 
and  king  are  annoyed.  As  a  matter  of  course,  many  of 
these  patients  have  been  transferred  to  an  asylum  before 
matters  have  come  to  such  a  pass. 

I  will  now  pause  a  little  in  the  description  in  order  to 
complete  the  history  in  a  few  details.  We  have  hitherto 
spoken  intentionally  only  of  the  auditory  hallucinations, 
because  they  are  so  disproportionately  frequent  and  also 
because  they  furnish  the  most  distinct  idea  concerning  the 
nature  of  verruecktheit.  There  is  sometimes  a  real,  but 
usually  only  an  apparent  absence  of  auditory  hallucina- 
tions in  verruecktheit.  This  is  probably  owing  to  the 
fact  that  the  strength  of  the  innervation  currents  to  the 
speech  muscles  is  not  always  so  great  that  it  appears  to 
the  patient  as  distinct  internal  speech.  These  gradual 
differences  between  undoubted  original  notions  of  his  own 
brain  and  those  which  appear  to  be  forced  upon  him  from 
without,  but  are  really  only  another  expression  of  the  same 
process,  make  it  so  difficult  for  him  to  distinguish  between 
reality  and  deception. 

But  the  disease  is  very  often  attended  with  a  series  of 
other  hallucinations.  Hallucinations  of  common  sensa- 
tion, especially  in  the  skin  and  internal  organs,  are  apt  to 
develop  into  delusions.  The  knowledge  of  physical  appa- 
ratus is  generally  utilized  in  explanation.  The  terms 
electricity  and  magnetism  are  usually  employed  to  cover 
the  indefinite  notions  concerning  the  supposed  underlying 
physical  processes.  The  disorders  of  common  sensation 
consist  of  vertigo,  shocks  of  the  entire  body ;  the  bed  is 
drawn  upward,  the  limbs  are  moved  against  the  patient's 
16 


242  HANDBOOK   OF   INSANITY. 

will ;  burning  boring  pains  alternate  with  tearing,  draw- 
ing of  the  limbs.  Even  new  words  are  formed  in  order 
to  express  the  annoying  sensations.  It  is  often  difficult  to 
distinguish  the  real  hallucination  from  its  fantastic  expla- 
nation and  amplification,  because  many  patients  do  not  lose 
the  tendency  to  exaggeration  even  during  the  disease.  This 
one  complains  that  his  brain  is  torn  out,  the  other  that 
his  spinal  cord  is  removed;  this  one's  skull  is  opened  and 
shut,  the  other  has  a  wire  drawn  through  his  head ;  or  a 
stone  or  one  of  the  other  organs  has  taken  the  place  of  the 
brain.  The  thoracic  and  abdominal  viscera  are  very  often 
implicated ;  they  are  replaced  by  wheels,  the  heart  is  de- 
prived of  blood  and  pumps  only  air  into  the  vessels,  the 
rectum  is  torn  out  or  a  mill-stone  lies  in  front  of  it.  All 
this  is  done  by  the  secret  contrivances  of  his  enemies. 
They  torment  him  day  and  night,  exchange  his  limbs, 
place  microscopic  animals  under  his  skin,  etc.  If  these 
feelings,  under  the  influence  of  superstitious  notions,  are 
attributed  to  a  supernatural  devilish  cause,  and  if  alter- 
nating auditory  hallucinations  confuse  the  patient's  con- 
duct, they  result  in  the  delusion  of  "possession."  The 
enemies,  the  devils,  reside  in  the  patient's  ears  and  deafen 
him  with  their  terrible  outcries,  they  rise  from  his  belly 
into  his  head,  they  utter  blasphemous  remarks  which  he 
must  communicate  to  the  whole  world.  He  preaches  the 
sinfulness  of  the  world  and  foretells  the  day  of  judgment, 
but  at  the  same  time  feels  himself  compelled  to  cry  out 
against  his  will.  He  says  that  the  devil  is  in  him  and 
forces  him  to  such  acts.  The  most  remarkable  descrip- 
tions and  explanations  are  reported  by  the  patient  con- 
cerning the  sexual  apparatus,  and  such  notions  are  sup- 
plemented by  visual  hallucinations.  Men  see  themselves 
surrounded  by  naked  women.  Women  experience  the 
act  of  coitus;  at  the  same  time  they  are  usually  violent 
and  irritated,  slam  the  doors  and  break  objects;  more 
rarely  they  revel  in  voluptuous  feelings  or  perhaps  in  the 
thought  that  they  have  become  pregnant  with  the  Saviour 
of  the  world. 


DELUSIONS   OF    GRANDEUR.  243 

In  close  relation  with  the  feeling  of  being  possessed, 
which  often  has  a  religious  tinge,  we  find  olfactory  hallu- 
cinations. In  fact,  a  division  of  verruecktheit  according 
to  the  different  forms  of  hallucinations  is  not  possible,  be- 
cause the  auditory  hallucinations  alone  occupy  a  special 
position;  the  other  forms  are  combined  in  manifold  ways. 
Certain  ones,  however,  are  more  often  found  in  combina- 
tion; we  have  already  referred  to  the  combination  of 
olfactory  and  genital  hallucinations  which  often  occur  in 
religious  ideas.  Sulphur  and  pitch,  poisonous  vapors,  are 
conveyed  to  the  patient  in  the  most  remarkable  ways. 
The  stench  comes  through  the  chimney,  the  cracks  in  the 
floor,  or  specially  constructed  pipes.  The  patient  plugs 
his  nostrils  with  cotton,  cloth,  etc.  As  gustatory  and 
olfactory  hallucinations  are  often  combined,  the  food 
tastes  like  urine  and  faeces,  arsenic,  or  chloroform.  Many 
of  these  patients  are  constantly  spitting  in  order  to  get 
rid  of  the  distressing  sensations.  It  is  clear  to  him  that 
he  is  to  be  poisoned ;  he  takes  the  greatest  precautions  in 
eating  his  meals,  changes  his  restaurant  at  every  meal, 
has  chemical  examinations  made,  etc. 

Visual  hallucinations  are  the  rarest,  and  generally  con- 
sist only  of  shadowy  appearances  or  fantastic  embellish- 
ments of  illusions.  At  all  events  the  patient  suffers  much 
less  from  visual  hallucinations  than  does  the  one  who  is 
filled  with  delusions  of  grandeur. 

We  will  now  consider  the  delusion  of  grandeur.  Apart 
from  the  fact  that  it  may  occur  with  or  without  halluci- 
nations, we  must  distinguish  whether  it  develops  inde- 
pendently at  the  beginning  of  the  disease  or  whether  it 
develops  out  of  the  delusion  of  persecution.  The  latter 
variety,  although  perhaps  less  frequent  than  the  former, 
will  be  first  considered.  In  a  few  cases  a  logical  deduc- 
tion of  the  ideas  of  grandeur  from  the  delusion  of  perse- 
cution may  be  traced.  On  account  of  the  constant  per- 
secutions to  which  he  is  subjected  he  reaches  the  suspicion 
and  finally  the  positive  conclusion  that  he  is  persecuted 
because  of  his  resemblance  to  some  prominent  individual, 


244  HANDBOOK   OF   INSANITY. 

or  because  he  himself  occupies  some  important  position. 
The  general  observation  by  others  must  have  some  special 
reason.  Now  everybody  looks  at  him  respectfully,  the 
newspapers  furnish  hints  which  make  it  clear  to  him  that 
all  his  persecutions  were  due  to  his  commanding  person- 
ality. Increased  self-esteem  and  expansive  ideas  may  thus 
develop  psychologically  in  connection  with  the  ideas  of  per- 
secution. But  the  special  character  of  the  exalted  ideas 
depends  mainly  upon  the  hallucinations.  A  feeling  of 
magnetic  currents  and  the  notion  of  awaking  suddenly  to 
new  life  occur  in  this  connection,  and  hence  the  change 
often  takes  place  suddenly.  With  hardly  any  preliminary 
sign  the  patient  suddenly  announces  that  he  is  a  prince, 
king,  the  Son  of  God,  the  Messiah.  This  may  result  from 
some  trifling  circumstance,  but  more  often  from  a  true  hal- 
lucination, especially  of  hearing.  A  voice  from  heaven 
or  the  apparition  of  an  angel  announces  to  him  his  lofty 
position.  Hence  verruecktheit  so  often  has  a  religious 
basis,  furnishing  prophets,  apostles,  the  bride  of  Christ, 
the  Virgin  Mary.  Corresponding  to  the  original  develop- 
ment out  of  ideas  of  persecution,  a  struggle  is  often  main- 
tained for  some  time  between  the  powers  of  evil  and 
the  divine  influences,  but  finally  results  in  the  victory  of 
God's  elect.  From  time  to  time  the  struggle  is  again  re- 
newed and  temporarily  the  exalted  mood  is  clouded,  but 
renewed  visions,  delightful  odors,  and  feelings  of  pleasure 
confirm  the  former  opinion.  The  weakness  of  judgment 
is  often  so  great  that  the  patient  proclaims  himself 
Messiah  and  king  in  the  same  breath,  and  this  terminates 
occasionally  in  a  wild  mixture  of  confused  ideas  of  grand- 
eur, which  are  rarely  interrupted  by  ideas  of  persecution. 
But  usually  the  exalted  ideas  remain  constant  for  years 
and  the  patients  are  accustomed  to  postpone  the  fulfilment 
of  their  wishes  to  later  times.  These  individuals  do  not 
long  remain  out  of  an  asylum.  The  patient,  knowing 
himself  heir  to  a  throne,  writes  letters  to  the  real  incum- 
bent. The  second  Son  of  God  sends  around  printed  pam- 
phlets in  which   he  calls  the  pope  Anti-Christ.      Such 


CHARACTER    OF   ACTS    OF   VIOLENCE.  245 

harmless  acts  are  often  accompanied  by  dangerous  attacks 
upon  others.  A  supposed  slanderous  remark  induces  the 
patient  to  beat  a  passer-by  on  the  street;  armed  with 
weapons  against  his  enemies  he  shoots  the  one  whom  he 
considers  the  arch-conspirator.  Another  hears  a  divine 
voice,  "kill  him,"  and  immediately  stabs  a  by-stander;  a 
church  or  house  is  put  to  flames  either  from  revenge  or  to 
serve  as  a  shining  beacon  to  the  glory  of  God.  On  the 
other  hand,  he  does  violence  to  his  own  body ;  self -muti- 
lations, even  suicides,  are  observed. 

These  patients  also  become  nuisances  by  their  constant 
complaints  to  the  authorities  against  their  enemies  or  by 
the  incessant  pleading  of  their  cause  in  print.  The  one 
who  is  suffering  from  a  delusion  of  persecution  is  not  con- 
tent with  lamentation  and  complaining,  but  the  most 
intense  feelings  of  opposition  and  revenge  do  not  let  him 
rest.  He  complains  to  the  courts  in  endless  reports,  and 
without  even  waiting  for  an  answer  he  may  mete  justice 
with  his  own  hands.  This  constitutes  an  important  dif- 
ference between  the  murder  committed  in  verruecktheit 
and  in  melancholia.  The  former  is  the  result  of  hatred  or 
assumed  justifiable  resistance ;  the  latter  is  often  associated 
with  feelings  of  profound  pity. 

We  have  just  considered  the  development  of  the  delu- 
sion of  grandeur  from  the  delusion  of  persecution,  and 
will  now  discuss  its  coincident  and  independent  develop- 
ment. 

A  patient  suddenly  receives  from  a  higher  power  the  mes- 
sage, "  You  are  perfect,  you  will  not  die,  but  keep  quiet." 
She  does  not  remain  quiet,  but  tells  her  experience  on  the 
following  day ;  soon  afterward  she  feels  and  hears  that 
she  is  damned.  But  the  effect  of  the  message  again  ex- 
alts her,  and  for  a  time  she  looks  forward  with  joy  to  the 
day  of  judgment.  At  the  end  of  some  months  a  new 
voice  tells  her  that  she  may  not  eat  or  she  will  be  damned 
eternally ;  nevertheless  she  eats  and  for  years  afterward 
feels  that  eternal  damnation  is  her  lot ;  instead  of  being 
the  most  perfect  creature  on  earth,  she  has  become  the  evil 


246  HANDBOOK   OF   INSANITY. 

woman,  the  serpent.  This  notion  in  turn  disappears  after 
the  lapse  of  years,  and  the  exalted  feeling  that  she  is  per- 
fect and  eternal  dominates  the  further  course  of  the  dis- 
ease. In  a  similar  way  we  find,  from  the  start,  ideas  of 
exaltation  and  derogation  alongside  of  one  another  in  more 
or  less  intimate  association.  The  more  violently  the  dis- 
ease begins  the  more  closely  joined  are  these  apparently 
antagonistic  ideas,  and  they  appear  directly  out  of  con- 
sciousness without  any  logical  connection. 

The  same  ideas  recur  in  many  different  patients,  and  it 
almost  appears  as  if  one  had  learned  them  from  another. 
This  can  only  be  explained  by  their  original  organic  de- 
velopment, as  in  the  case  of  central  hallucinations ;  hence, 
also,  their  convincing  power,  which  is  so  much  greater 
the  more  vivid  the  sensory  accompaniment  in  the  shape 
of  hallucinations.  After  a  while  an  arrangement  of  the 
antagonistic  delusions  is  effected,  and  in  the  course  of 
years  they  grow  together  into  a  system. '  The  degree  of 
logical  connection  and  psychological  foundation  of  the 
originally  independent  series  of  ideas  depends  upon  the 
grade  of  intelligence  which  still  remains  intact. 

A  patient  states  that  she  cannot  rid  herself  of  the  idea 
that  she  is  a  princess,  and  at  the  same  time  she  hears  that 
she  may  not  eat.  She  is  astonished  at  the  first  fact  and 
distressed  about  the  second ;  she  fasts,  and  only  at  a  much 
later  period  does  she  explain  the  connection  by  stating  that 
a  period  of  probation  must  first  be  endured  before  attain- 
ing her  high  destiny.  This  cerebral  mode  of  development 
of  antagonistic  concepts  is  not  really  surprising  if  we 
remember  the  rapid  alternation  of  cheerful  and  mournful 
ideas  in  mania  and  other  psychoses. 

The  new  thoughts  at  first  astonish  the  patient,  and  it  is 
only  gradually  that  they  unite  with  the  fund  of  ideas 
already  present.  It  is  important  to  note  that  profound 
affects  of  long  duration  do  not  attend  the  origin  of  such 
delusions. 

We  turn  next  to  the  consideration  of  verruecktheit 
without  hallucinations. 


SYMPTOMS   IN   CHILDHOOD.  247 

This  always  presupposes  a  mental  basis  which  is  below 
par.  The  acceptance  of  the  delusions  is  only  made  possi- 
ble here  by  a  weakness  of  judgment  which  is  always  either 
congenital  or  has  developed  in  early  childhood.  On  the 
other  hand,  a  so-called  original  verruecktheit  may  also  be 
associated  with  hallucinations,  and  then  constitutes  a  va- 
riety midway  between  the  already  described  forms  and 
the  simple  verruecktheit  which  we  are  about  to  discuss. 
There  are  numerous  transitional  forms,  but  a  description 
of  pronounced  differences  should  be  attempted  in  order  to 
show  more  clearly  the  individual  symptoms.  But  it  must 
not  be  forgotten  that  the  hallucinatory  delusion  of  perse- 
cution and  grandeur  develops  generally  on  the  basis  of 
hereditary  taint.  If  we  here  attach  the  chief  importance 
to  this  early  developed  basis  and  if  the  term  original  ver- 
ruecktheit is  not  employed  for  this  simple  form  of  the 
disease,  it  is  due  to  the  fact  that  this  term  has  become 
naturalized  in  psychiatry  as  applied  to  verruecktheit, 
developing  upon  the  hereditary  basis  and  associated  with 
hallucinations.  It  would  be  more  correct  to  apply  this 
term  also  to  the  simple  forms  without  hallucinations. 

We  have  to  deal,  accordingly,  with  individuals  in  whom 
the  origin  of  the  disease  dates  back  to  earliest  youth,  pe- 
culiarities being  noticeable  in  the  child  in  all  the  domains 
of  thought  and  feeling.  There  is,  however,  an  early  dis- 
tinction in  the  main  direction  of  thought,  either  toward 
the  side  of  derogation  or  of  exaltation,  or  the  combination 
of  these  notions  is  an  early  one. 

We  begin  with  the  first  form  in  which  self-depreciation 
constitutes  the  essence  of  the  disease.  At  an  early  period 
the  child  feels  himself  neglected  by  his  parents,  brothers 
and  sisters,  and  finally  becomes  antagonistic,  in  a  measure, 
to  his  family.  These  thoughts  gain  more  and  more 
strength,  and  finally  they  begin  to  influence  his  percep- 
tions. He  thinks  himself  neglected  by  other  children 
and  sees  hostile  distrust  in  the  shyness  of  boys  of  his  age. 
Such  children  are  much  alone  and  often  have  a  tendency 
to   extensive   promiscuous   reading;    they  meditate   and 


248  HANDBOOK   OF   INSANITY. 

dream  concerning  all  sorts  of  queer  notions.  Derided  by 
his  companions  the  child  becomes  more  sensitive,  and  from 
the  morbid  predisposition  the  fully  developed  psychosis 
slowly  grows.  Not  alone  the  reproaches  of  others,  called 
forth  by  the  patient's  peculiar  conduct,  but  even  the  most 
harmless  circumstance  is  manipulated  into  a  coherent  sys- 
tem. A  progressive  psychological  development  is  usually 
more  distinct  in  verruecktheit  without  hallucinations  than 
in  the  so-called  hallucinatory  form.  Gradually  all  per- 
ceptions become  confirmations  of  the  constantly  crystalliz- 
ing ideas  of  derogation ;  in  married  life  this  appears  often 
in  the  shape  of  jealousy. 

It  is  especially  interesting  to  follow  the  comparatively 
frequent  transition  into  ideas  of  exaltation,  while  the 
further  course  of  the  delusion  of  persecution  in  simple  ver- 
ruecktheit is  the  same  as  in  the  hallucinatory  form.  As 
a  rule  these  persons  have  an  exaggerated  idea  of  their 
own  abilities  even  in  early  childhood.  They  dream  of 
lofty  ideals — the  family  life  is  not  sufficiently  aristocratic. 
The  sensitiveness  and  irritability  in  the  bosom  of  the 
family  are  the  same  as  in  the  form  of  disease  just  de- 
scribed. As  a  premature  physical  development  often 
accompanies  the  peculiar  mental  character,  they  are 
brought  prematurely  among  grown  people.  Friendly 
words  and  harmless  flattery  make  a  deep  impression  upon 
these  children  and  give  rise  to  the  notion  that  they  are 
destined  for  something  higher.  In  their  dreams  they  see 
themselves  members  of  cultured  circles  of  society,  and  in 
waking  moments  these  serve  as  the  basis  for  building 
castles  in  the  air.  The  notion  of  aristocratic  descent  now 
appears  occasionally  and  is  supported  by  the  supposed  un- 
feeling treatment  at  home  and  the  kind  manner  of  outsiders. 
The  suspicion  that  they  are  the  children  of  other  parents 
becomes  stronger  and  stronger  and  requires  its  psycho- 
logical realization;  this  is  effected  undeniably  by  the 
weakness  of  judgment.  In  a  perhaps  real  but  very  slight 
resemblance  to  the  picture  of  a  ruling  sovereign  the  pa- 
tient recognizes  the  secret  of  his  birth.     Cautiously  he 


EROTIC   AND   RELIGIOUS    SYMPTOMS.  249 

endeavors  to  gain  information  on  this  point  from  his 
parents.  They  are  naturally  astonished,  perhaps  con- 
fused, and  thus  his  suspicions  are  confirmed.  The  reason 
of  former  slights  now  becomes  clearer,  and  out  of  the  an- 
tagonism of  self -depreciation  and  exaltation  is  gradually 
developed  the  coherent  series  of  delusions.  According  as 
either  of  these  series  predominates,  the  clinical  history 
may  resemble  that  of  delusions  of  persecution  or  of 
grandeur. 

The  history  often  receives  a  special  color  from  erotic  or 
religious  elements.  In  many  cases  both  develop  in  early 
youth  and  increase  in  intensity  at  the  period  of  puberty.. 
Religious  enthusiasm  and  masturbation  are  found  associ- 
ated, but  Platonic  feelings  may  also  be  marked  without 
sexual  aberrations.  Temptations  by  the  devil  alternate 
with  feelings  of  inspiration ;  the  interpretation  of  texts  in 
the  Bible  facilitates  the  development  of  a  delusional  sys- 
tem. The  enthusiasm  or  humility  which  accompany 
their  faith  or  doubts  are  rarely  profound  affects;  they 
make  sport  of  the  feelings  of  sinfulness  and  atonement. 
This  constitutes  a  difference  from  those  cases  of  verrueckt- 
heit  in  which  hallucinations  exert  full  power  over  action ; 
here  we  are  more  apt  to  find  refusal  to  take  food,  complete 
mutism,  self -mutilations,  and  even  crucifixion  and  also 
violence  against  others.  Another  form  of  the  delusion 
of  grandeur  develops  in  the  domain  of  invention  or  the 
improvement  of  existing  conditions.  Queer  originals  are 
always  numerous  in  society ;  in  riots  and  other  forms  of 
social  excitement  they  appear  in  greater  numbers,  and 
not  infrequently  lead  the  masses.  In  quiet  times  they  are 
a  torment  to  their  fellows  until  some  irrational  act  leads 
them  to  the  asylum. 

As  we  have  already  remarked,  the  independent  original 
development  of  a  delusion  of  grandeur  is  very  rare,  but 
there  are  some  cases,  especially  of  an  hereditary  charac- 
ter, in  which  the  ideas  of  depreciation  are  rare  and  so  over- 
shadowed by  the  delusion  of  grandeur  that  the  former  is 
unnoticed.     Hallucinations,  especially  visions,  are  gener- 


250  HANDBOOK   OF   INSANITY. 

ally  present  in  such  cases.  These  forms,  which  are  always 
more  violent,  terminate  early  in  confusion,  and  the  delu- 
sion then  has  a  disorderly  and  monstrous  character. 
Every  question  provokes  fantastic  answers.  The  patient 
is  poet,  philosopher,  general,  discoverer,  at  the  same  time ; 
astonishment  at  such  remarks  leads  to  further  exaggera- 
tions, such  as  "  I  am  the  world,  or  God." 

We  find,  accordingly,  that  as  soon  as  we  leave  the  gen- 
eral, somewhat  schematic  description  and  turn  to  a  special 
form  of  the  disease,  numerous  transitions  are  found  be- 
tween the  different  forms  of  verruecktheit. 

Before  proceeding  further  with  the  general  description 
we  will  describe  the  so-called  insanity  of  querulents,  which 
has  occasional  points  of  contact  with  all  the  varieties  al- 
ready discussed. 

Atlhough  the  individuals  who  suffer  from  this  form  of 
the  disease  usually  have  an  hereditary  taint,  the  outbreak 
of  the  disease  does  not  take  place,  as  a  rule,  until  a  later 
period  of  life,  though  a  number  of  peculiarities  had  long 
been  evident.  The  special  exciting  cause  is  always  some 
defeat  in  a  court  of  law.  The  irritable  mood  then  permits 
a  false  interpretation  of  the  actual  facts.  A  tinge  of  ex- 
cessive self-appreciation  without  decided  delusions  of 
grandeur  causes  from  the  start  an  irritated  opposition  to 
the  supposed  injuries.  Hence  the  querulent  fights  for 
his  rights  everywhere  and  avenges  every  slight  with 
morbid  persistence,  especially  by  means  of  new  lawsuits. 
As  hallucinations  are  rare,  very  sudden  actions  are  not 
observed,  and  at  the  start  the  delusions  are  cautiously 
concealed.  It  is  then  often  difficult  to  arrive  at  a  conclu- 
sion. But  a  certain  degree  of  weakness  of  judgment  soon 
appears.  The  regardlessness  of  consequences  in  securing 
his  end  makes  the  patient  forget  his  real  interests ;  he  sac- 
rifices fortune,  health,  and  the  happiness  of  his  family. 
The  more  his  complaints  are  dismissed  by  the  courts,  the 
more  he  believes  in  the  partiality  and  corruption  of  the 
judges.  In  a  morbid  reliance  upon  himself  he  assumes  to 
possess  a  knowledge  of  the  law  and  legal  methods  and 


INSANITY   OP   QUERULENTS.  251 

pleads  his  own  case  before  the  authorities.  If  reprimanded 
for  his  conduct,  he  demands  a  change  in  the  laws  or  resists 
their  execution..  An  unbounded  egoism  thus  seeks  to  dis- 
place the  boundaries  of  the  law;  the  inner  excitement, 
which  is  constantly  growing  more  passionate,  no  longer 
confines  itself  strictly  to  the  truth.  The  disappearance  of 
the  last  remains  of  reason  is  shown  by  the  more  and 
more  impudent  demands,  and  the  passion,  which  is  no 
longer  held  under  control,  passes  all  bounds.  A  more  or 
less  pronounced  delusional  system  now  develops. 

The  mental  disorder  in  the  shape  of  verruecktheit  now 
becomes  more  distinct.  The  patient  becomes  the  pro- 
tector of  the  oppressed.  Plans  for  the  improvement  of 
the  law,  even  for  the  improvement  of  the  general  condi- 
tion of  mankind,  may  make  their  appearance,  and  thus 
there  is  a  transition  to  a  complete  form  of  verruecktheit. 
But  the  milder,  slowly  progressing  cases  are  often  difficult 
to  recognize  among  the  original  symptoms  growing  out  of 
the  irritable  mood.  The  patients  are  usually  removed  to 
an  asylum  at  an  early  period.  When  the  irritable  mood 
subsides,  we  are  often  surprised  at  the  great  degree  of 
weakness  of  judgment,  shown  by  the  unmeasured  demands 
in  consequence  of  the  supposed  injustice.  Sometimes  the 
patient  even  smiles  at  his  own  want  of  moderation.  At 
the  same  time  we  generally  find  that  he  has  become  in- 
different to  other  interests  and  that  his  feelings  and  de- 
sires are  devoid  of  mental  vigor. 

It  still  remains  for  us  to  consider  briefly  a  few  phenom- 
ena which  may  occur  in  all  complete  forms  of  verrueckt- 
heit. The  use  of  peculiar,  self-formed  words  is  frequent, 
generally  in  association  with  auditory  hallucinations, 
sometimes  with  hallucinations  of  feeling.  More  rarely 
the  verbal  monstrosities  are  perverse  expressions  of  insane 
ideas,  and  this  is  seen  most  frequently  in  the  transition  of 
the  disease  into  confusion.  A  few  examples  will  show  the 
character  of  these  words ;  the  physician  is  received  daily 
with  the  salutation,  "Rokamohel,  Rodababa."  One  pa- 
tient  calls   himself   "  paraweitzika, "    another    speaks  of 


252  HANDBOOK   OF   INSANITY. 

"  pulanus  gekatekowbet, "  etc.  The  writing  of  these  pa- 
tients exhibits  the  same  characteristics. 

It  is  very  difficult  to  give  a  general  description  of  the 
outward  bearing  of  the  patients,  but  a  common  feature  in 
many  cases  is  a  certain  perversity  and  crankiness  of  ex- 
pression and  conduct.  But  this  cannot  be  attributed  to 
the  mental  condition,  because  congenital  peculiarities  of 
the  skull  and  face  sometimes  impart  a  certain  direction 
to  every  expression.  The  more  the  verruecktheit  is  based 
upon  the  general  development  of  the  patient,  the  more 
frequently  do  we  also  find  other  malformations,  and  with- 
out exaggerating  their  importance  they  sometimes  con- 
firm an  unfavorable  prognosis. 

Inequality  of  the  pupils  is  frequent,  but  has  no  great 
significance.  Temporary  relaxations  of  groups  of  mus- 
cles, but  not  paralyses,  are  observed,  and  also  occasional 
twitchings.  These  may  be  defensive  movements  result- 
ing from  delusions.  Motor  inhibition  and  cataleptic 
rigidity  are  rare  or  seen  chiefly  in  the  transition  into  con- 
fusion ;  the  rigidity  is  often  confined  to  certain  groups  of 
muscles.  In  some  cases  tension  is  noticeable  in  the  entire 
mental  condition.  These  conditions  may  disappear  in  a 
few  weeks  or  may  become  chronic;  the  delusions  then 
become  less  distinct,  and  a  final  termination  in  dementia 
is  to  be  expected. 

Other  motor  disorders,  such  as  tremor,  permanent  pa- 
ralysis, general  convulsions,  do  not  belong  to  the  clinical 
history,  but  are  accidental  symptoms.  If  retention  of 
urine  and  fseces  happens  to  be  present  and  disease  of  the 
spinal  cord  can  be  excluded,  we  should  suspect  voluntary 
retention.  For  example,  one  patient  did  not  wish  to  lose 
the  golden  contents  of  his  rectum. 

Sleep  is  normal  unless  disturbed  by  violent  delusions 
and  hallucinations,  and  the  general  nutrition  is  also 
excellent. 

Verruecktheit  is  one  of  the  most  frequent  of  mental  dis- 
orders. On  account  of  the  numerous  cases  which  appear 
at  the  climacteric,  the  female  sex  is  attacked  more  f re- 


TERMINATIONS.  253 

quently  than  the  male.  Apart  from  those  cases  in  which 
the  patients  have  been  morbid  from  earliest  childhood  and 
the  verruecktheit  has  developed  imperceptibly  out  of  the 
constitutional  predisposition,  the  disease  appears,  in  the 
majority  of  cases,  at  the  development  of  puberty,  i.e.,  the 
end  of  the  second  and  beginning  of  the  third  decennium. 
It  may  begin,  however,  at  any  period  of  life,  but  most 
rarely  in  old  age. 

The  disease  usually  runs  a  very  chronic  course.  It  is. 
often  preceded  by  a  period  of  depression,  more  rarely  it 
apparently  begins  suddenly  with  violent  symptoms,  but 
then  the  previous  development  has  merely  been  concealed. 
As  a  rule,  it  progresses  by  fits  and  starts,  and  there  is 
hardly  any  psychosis  which  exhibits  such  protracted  and 
notable  remissions.  With  the  subsidence  of  hallucina- 
tions and  their  accompanjdng  affects,  there  is  a  certain 
improvement  in  many  cases.  Although  still  convinced 
of  the  truth  of  their  delusions,  the  patients  are  able  to  re- 
strain them  and  are  not  influenced  by  them  in  their  actions. 
Slight  peculiarities  of  conduct  and  the  retention  of  some 
apparently  subsidiary  parts  of  the  delusions,  together 
with  a  certain  reluctance  to  discuss  the  morbid  ideas,  tes- 
tify to  the  incompleteness  of  recovery.  The  patients  often 
dissimulate  with  great  skill  in  order  to  obtain  their  dis- 
charge from  the  asylum. 

The  terminations  of  the  disease,  therefore,  are  incom- 
plete recovery,  a  chronic  state,  confusion,  imbecility,  or 
death.  Recovery  is  very  rare,  but  improvement  is  often 
so  pronounced,  especially  in  delusions  of  grandeur,  that 
a  return  to  the  former  occupation  becomes  possible.  The 
previous  weakness  of  judgment  and  general  mental  inva- 
lidism persist.  The  progressive  mental  decay  is  more 
pronounced  when  the  clearly  established  disease  continues 
for  years  or  even  for  life.  The  transitions  into  confusion 
and  imbecility  are  gradual.  The  highest  grades  of  de- 
mentia are  not  observed,  as  memory  is  never  lost.  Death 
may  occur  from  suicide  or  accidental  complications. 

In  a  psychosis  which  is,  on  the  whole,  incurable,  the 


254  HANDBOOK   OF   INSANITY. 

treatment  can  only  be  directed  against  individual  groups 
of  systems,  and  even  this  is  extremely  difficult  in  ver- 
ruecktheit.  We  already  know  that  these  patients,  espe- 
cially when  suffering  from  hallucinations,  are  dangerous 
members  of  society.  Hence  they  should  be  sent  to  an 
asylum,  at  least  in  the  beginning.  After  the  lapse  of 
time,  when  imbecility  or  confusion  have  destroyed  the  rare 
affects,  they  may  be  transferred  to  colonies  of  insane,  to 
the  care  of  a  family,  or  perhaps  to  their  own  home. 

3.   Confusion. 

The  confusion  here  referred  to  is  not  separated  sharply 
from  verruecktheit ;  its  relation  to  paranoia  is  indicated 
by  the  combination,  although  not  firmly,  of  former  delu- 
sions. The  series  of  ideas  are  only  held  together  by  a 
loose  chain.  Temporary  affects  threaten  the  remainder  of 
the  connection  while  a  certain  degree  of  mental  weakness 
is  recognizable  in  quiet  thought,  and  an  attempt  is  no 
longer  made  to  find  a  logical  basis  for  the  delusion  which 
appears  only  temporarily  in  the  affect.  It  is  evident, 
therefore,  that  this  form  of  confusion  may  develop  from 
wahnsinn,  mania,  and  melancholia ;  it  is  therefore  a  sec- 
ondary form  of  paranoia.  The  absence  of  dementia  is 
shown  by  the  fact  that  the  patient  can  often  reason  cor- 
rectly concerning  things  which  do  not  refer  to  his  morbid 
personality. 

Confusion  affords  an  excellent  illustration  of  the  funda- 
mental principle  of  all  mental  disorders  that  notions  which 
appear  involuntarily  always  gain  a  predominance  over 
those  which  are  selected  consciously.  Hence  confusion 
is  often  the  termination  of  mental  disease.  Thus  it  is 
found  after  melancholia  when  the  violent  constant  affect 
disappears,  but  the  delusions  remain  and  mental  weakness 
appears.  We  also  meet  with  the  conditions  known  occa- 
sionally as  acute  hallucinatory  confusion,  and  which  were 
discussed  among  the  violent  forms  of  mania.  If  these 
pass  into  chronic  excitement  the  confusion  becomes  more 


TERMINAL   CONFUSION.  255 

constant,  although  remissions  recur  continually  and  ena- 
ble us  to  recognize  that  a  combination  of  the  delusions  is 
still  attempted.  Although  these  delusions  form  no  defi- 
nite system,  they  prove  that  the  disease  is  a  secondary 
paranoia. 

There  are  still  other  psychoses  which  either  run  their 
course  with  or  terminate  in  distinct  confusion ;  for  exam- 
ple, the  mental  disorder  attending  epilepsy  and  neuras- 
thenic conditions  of  exhaustion.  They  hardly  ever  exhibit 
a  delusional  system,  because  this  is  not  permitted  by  the 
obscuration  of  consciousness;  hence  this  confusion  does 
not  belong  to  paranoia. 

Whatever  the  manner  in  which  confusion  has  developed, 
loosely  connected  series  of  delusions  are  more  or  less  dis- 
tinctly recognizable.  But  they  are  lacking  in  firm  sys- 
tematization,  and  this  is  only  indicated  by  single  words  or 
sentences ;  from  the  frequent  repetition  of  such  words  and 
sentences  we  can  sometimes  distinguish  the  morbid  psy- 
chical condition  which  preceded  the  confusion.  If  hallu- 
cinations are  still  present  (and  this  is  true  of  not  a  few 
cases)  they  usually  find  a  more  distinct  expression  in  sud- 
den movements  and  individual  acts  than  in  the  confused 
speech.  But  both  the  delusions  and  hallucinations  have 
lost  their  compelling  hold  upon  the  feelings  and  actions  of 
the  patient.  They  appear  and  disappear  with  equal  ra- 
pidity. The  play  of  ideas  has  no  internal  connection  and 
varies  with  accidental  circumstances.  But  conditions  of 
greater  activity  alternate  with  periods  of  quiet  and  in- 
creased rationality,  in  which  the  patient  may  give  some 
information  concerning  the  hallucinations  and  delusions 
which  he  has  had. 

It  is  difficult  to  describe  the  endless  varieties  in  the  man- 
ifestations of  confusion.  Even  in  higher  grades  memory 
is  not  entirely  lost,  except  for  recent  events.  The  dis- 
placement of  the  standpoint  of  his  own  personality,  which 
formed  the  centre  of  the  former  systematized  delusions  of 
the  patient,  remains  unchanged  longest.  Hence  we  find, 
for  example,  a  senseless  repetition  of  large  figures,  of  fan- 


256  HANDBOOK   OF   INSANITY. 

tastic  images  of  the  patient's  own  worth;  but  the  talk  of 
millions,  etc.,  has  become  merely  a  play  of  words.  Ideas 
of  derogation  disappear  more  readily  in  the  confused 
speech.  Although  profound  emotions  are  lacking,  tem- 
porary excitement  is  very  common  and  may  be  attended 
with  sudden  acts  of  violence,  so  that  the  patient  is  often 
very  dangerous.  The  execution  of  definite  plans  is  im- 
possible because  the  will  is  too  unstable.  The  habits 
of  previous  days  of  activity  lead  only  to  the  performance 
of  minor  mechanical  actions  and  make  some  of  the  patients 
useful  members  of  the  household  of  an  asylum. 

As  a  matter  of  course,  confusion  develops  gradually  from 
the  previously  mentioned  conditions,  and  transitions  may 
be  pictured  in  all  stages ;  depressed  or  elevated  moods  still 
alternate  frequently.  A  cheerful  manner  mingled  with 
conceit,  anxiety  in  expression  and  gesture,  malice,  obsti- 
nacy, are  observed.  Many  patients  can  answer  brief  ques- 
tions, especially  those  which  concern  the  details  of  every- 
day life,  but  as  soon  as  we  ask  concerning  the  cause  of  their 
illness  or  touch  upon  any  of  the  relations  of  the  mental 
personality,  they  rapidly  become  confused  and  give  sense- 
less, incomprehensible  answers.  This  is  most  distinct 
when  they  are  asked  to  write,  as  in  the  following  frag- 
ment of  a  letter :  "  My  dear,  truly  married  Emperor  Will- 
iam in  Berlin !  As  my  truly  beloved  has  been  vouchsafed 
to  your  loyal  right  hand  and  to  what  belongs  to  it  through 
the  death  of  your  dear  Emilia,  and  as  so  many  hours  of 
grief  have  been  accorded  to  us,  we  will  with  our  dear 
brothers  of  pain,  as  you  have  communicated  to  my  dear 
Emilia  from  your  couch,  so  that  I  can  no  longer  retain 
my  beloved  of  your  absence  any  longer  in  my  heart,"  etc. 
In  speaking  the  flow  of  thought  is  naturally  interrupted 
by  external  circumstances  and  is  drawn  into  other  direc- 
tions, but  this  cannot  be  followed  except,  perhaps,  with 
the  aid  of  a  phonograph.  The  following  will  serve  as  an 
illustration  of  confused  remarks :  "  My  children  poisoned 
with  wine — powder  that  stunk — your  name  is — actually 
murder  a  woman — fat  and  oil — the  water  costs  money — 


DESCRIPTION  OF  PLATE  V. 

PARANOIA. 

Characteristic  pictures  of  the  variety  of  paranoia  known  as 
wahnsinn  could  not  be  obtained. 

The  pictures  of  the  old  man  illustrate  verruecktheit  with  halluci- 
nations in  the  form  of  delusions  of  persecution.  He  tasted, 
smelled,  and  felt  that  he  was  poisoned.  Intelligence  is  undisturbed, 
and  the  vigorous  expression  in  the  first  picture  is  due  to  the  fact 
that  he  wished  to  show  his  excellent  qualities  by  means  of  the 
photograph.  The  second  picture  was  taken  without  his  knowledge 
while  he  was  expatiating,  in  the  midst  of  his  delusions,  on  his 
former  strength  compared  with  his  present  miserable  condition. 
This  patient  often  communicates  by  telephone  with  his  enemies. 
He  then  sits  with  closed  eyes,  moves  the  lips  gently,  and  makes  slow 
movements  with  the  trunk.  This  is  shown  in  the  third  picture, 
which  was  taken  without  the  knowledge  of  the  patient. 

The  patient  shown  in  the  picture  to  the  right  and  below  also 
suffers  from  verruecktheit  with  hallucinations,  but  confusion  has 
already  occurred,  so  that  a  system  can  no  longer  be  recognized  in 
his  delusions.  Delusions  of  persecution  still  predominate,  especially 
as  the  result  of  auditory  hallucinations.  The  expression  of  the 
face  and  the  position  of  the  hand  show  cautious  distrust,  probably 
as  the  result  of  auditory  hallucinations  then  present.  The  uni- 
lateral wrinkling  of  the  forehead  is  habitual  in  this  patient,  is 
increased  by  every  affect,  and  must  be  regarded  as  a  spasmodic 
condition,  perhaps  as  a  sign  of  degeneration. 


HANDBOOK  OF  INSANITY. 

KIRCHHOFF. 


Plate  V. 


DESCRIPTION  OF  PLATE  VI. 

PARANOIA. 

The  two  upper  pictures  show  patients  in  whom  the  most  marked 
confusion  has  developed  out  of  verruecktheit.  The  man  formerly 
suffered  from  melancholic  delusions  of  derogation,  and  the  per- 
manent furrowing  of  the  forehead  corresponds  to  such  a  mood. 
The  furrowing  corresponds  very  closely  to  the  three  sides  of  a  tri- 
angle. The  lower  half  of  the  face  no  longer  presents  a  melancholic 
character ;  the  refractory  look,  the  firmly  closed  mouth,  and  the 
folded  arms  are  the  expression  of  dislike  to  sitting  quietly  while 
the  photograph  is  taken.  The  patient  is  usually  boisterous,  curses 
in  a  confused  way,  and  talks  against  "  voices. " 

The  woman  formerly  thought  herself  persecuted,  then  regarded 
herself  as  a  princess,  but  for  years  has  been  entirely  confused.  She 
is  generally  in  motion,  certain  imperative  movements  being  re- 
peated hundreds  of  times  a  day.  The  play  of  features  is  spasmodic 
and  often  changes,  so  that  it  corresponds  to  no  definite  expression. 

The  two  lower  pictures  show  verruecktheit  with  predominance  of 
ideas  of  grandeur  ;  intelligence  is  somewhat  impaired,  but  confusion 
has  not  yet  developed.  The  patient  was  very  willing  to  be  photo- 
graphed and  explained  each  time  what  he  meant  to  express  by  his 
position  and  gestures.  On  the  first  picture  he  speaks  "the  imperial 
word  in  a  commanding  tone ;"  in  the  second  one  "  the  Divine  word 
in  a  singing  tone." 


HANDBOOK  OF  INSANITY. 

KIRCHHOFF. 


Plate  VI. 


iifc*  «fi 


TERMINAL    CONFUSION.  257 

miserable  I  have  a  large  fortune."  Here  a  certain  loose 
connection  is  still  recognizable.  It  is  important,  however, 
to  know  that  the  confusion  may  be  entirely  absent  when 
simple  short  questions  are  propounded.  In  doubtful  cases 
this  is  an  important  differential  sign  from  conditions  of 
mobile  dementia  in  which' regular  series  of  thoughts  are 
no  longer  possible.  The  confusion  under  consideration 
does  not  pass  into  dementia ;  the  ability  to  perform  regular, 
although  only  mechanical,  acts  remains  intact. 

After  all  affects  have  subsided,  this  condition  may  last 
for  years  until  death  supervenes,  and  the  physical  condi- 
tion, particularly  sleep,  generally  remains  excellent. 
17 


III. 

MENTAL  DISORDERS  ASSOCIATED  WITH  PERMANENT  AN- 
ATOMICAL CHANGES  IN  THE  BRAIN  OR  WITH  GEN- 
ERAL  DISEASES. 

Introduction. 

We  have  heretofore  discussed  functional  disorders  which 
are  probably  due  to  chemical  changes  in  the  nervous  sub- 
stance. After  long  duration  and  great  violence  these  may 
lead  to  permanent  anatomical  tissue  changes,  and  hence 
we  meet  with  some  of  the  terminal  forms  of  the  functional 
psychoses  in  the  present  section.  This  classification  is  an 
artificial  one,  especially  when  we  must  here  describe  dis- 
eases without  anatomical  change,  merely  because  the 
clinical  history  is  identical  with  that  of  allied  conditions  in 
which  anatomical  changes  are  very  distinct.  Such  con- 
ditions are  primary  dementia  and  imbecility.  The  posi- 
tion of  these  two  conditions  in  this  section  appears  some- 
what more  justified  if  we  assume  that  the  anatomical 
changes  which  their  course  warrants  us  in  expecting  are 
not  found  simply  on  account  of  imperfect  means  of  exam- 
ination. 

The  functional  psychoses,  after  a  very  violent  course, 
show  that  the  chemical  morbid  processes  lead  to  tissue 
changes  and  in  this  way  sometimes  prove  fatal.  If  this 
fate  is  escaped,  the  permanently  resulting  anatomical 
changes  give  rise  to  symptoms  which  distinguish  them 
clearly  from  functional  disorders  and,  as  we  shall  soon 
see,  secondary  dementia  then  develops. 

The  connection  of  psychical  disorders  with  general 
affections  of  the  nervous  system  and  other  organs  and 
with  febrile  diseases  is  also  utilized  for  the  separate  de- 
scription  of   certain   psychoses.      This   division   is    also 

258 


PKIMARY   DEMENTIA.  259 

artificial  because  simple  mental  disorders  may  appear  at 
the  same  time  with  such  diseases  or  may  even  develop  in 
connection  with  them,  without  losing  their  own  indepen- 
dence. But  in  certain  cases  the  psychoses  develop  from 
these  diseases  in  such  an  intimate  connection  that  they 
thereby  receive  a  special  impress.  For  example,  a  para- 
noia upon  a  neurasthenic  or  alcoholic  basis  can  only  be 
described  in  this  connection. 

Senile  dementia  and  paralytic  dementia  are  perhaps  the 
only  psychoses  which  exhibit  a  definite  relation  between 
the  clinical  symptoms  and  the  anatomical  changes.  But 
we  often  meet  with  exceptions,  and  this  is  still  more  true 
of  the  other  psychoses  of  this  subdivision.  Moreover, 
there  are  sometimes  combinations  of  the  different  forms. 

It  must  also  be  remembered  that  there  are  not  alone 
many  impure  mixed  forms,  but  also  undeveloped  and 
therefore  indistinct  forms. 

A.    DEMENTIA. 

Dementia  is  acquired  as  the  result  of  disease,  while 
feeble-mindedness  may  be  congenital  or  acquired.  De- 
mentia may  begin  the  course  of  the  disease  and  then  either 
disappear  or  remain  permanent,  or  it  is  the  termination 
of  other  psychoses. 

The  former  variety,  viz.,  primary  dementia,  is  a  rare 
disease.  It  occurs  almost  entirely  among  young  individ- 
uals, occasionally  at  the  period  of  puberty,  but  chiefly  in 
men  in  the  thirties,  and  develops  almost  suddenly,  within 
a  few  hours  or  days.  The  causes  are  mental  or  physical 
exhaustion,  fright  or  mechanical  concussion  of  the  brain, 
hemorrhages,  the  puerperal  state.  The  affects  are  very 
slight;  hallucinations  and  delusions  are  absent.  Mem- 
ory is  rapidly  lost.  At  the  onset  a  certain  restlessness 
is  occasionally  observed,  and  a  few  purposeless,  even 
violent  acts  are  performed,  but  soon  there  is  complete  abo- 
lition of  all  mental  activity.  The  senses  are  blunted  and 
respond  slowly  to  stimuli.  The  ability  to  store  impres- 
sions is  considerably  diminished  or  entirely  abolished,  and 


260  HANDBOOK   OF   INSANITY. 

there  is  no  trace  of  voluntary  activity.  The  patient  does 
not  answer  questions,  must  be  fed,  and  only  eats  when 
food  is  placed  in  his  mouth.  He  remains  standing  for 
hours  in  one  spot  or  lies  motionless  in  bed.  The  face  is 
devoid  of  expression,  the  pupils  are  dilated  and  react 
slowly.  Sensibility  is  generally  lost,  so  that  even  strong 
electrical  currents  cause  no  impression ;  the  cutaneous  re- 
flexes are  diminished.  The  muscles  are  flabby,  but  in 
rare  cases  there  is  temporary  muscular  rigidity.  The 
heart's  action  is  feeble,  the  pulse  slow  and  small;  there  is 
often  oedema  of  the  feet  and  the  cyanotic  limbs  are  cool  to 
the  feel.  Sleep  is  quiet  and  profound.  The  temperature 
of  the  body  is  lowered,  and  the  weight  often  sinks  consid- 
erably, even  if  sufficient  food  is  ingested.  Respiration  is 
superficial.  In  the  most  severe  cases  the  faeces,  urine, 
and  saliva  escape  involuntarily. 

As  a  rule  this  condition  remains  uniform,  but  temporary 
excitement  occasionally  occurs,  during  which  the  patient 
sings,  whistles,  talks  incoherently  but  often  in  a  rhythmi- 
cal manner.  The  disease  generally  lasts  several  months, 
but  may  also  terminate  in  a  few  hours  or  days.  When 
the  disease  terminates  favorably,  as  is  true  of  the  majority 
of  cases,  the  face  gains  expression,  the  patient  begins  to 
speak  a  few  words  and  to  perform  a  few  movements 
slowly;  he  grows  cleanly  at  an  early  period.  The  nutri- 
tion improves  and  recovery  gradually  becomes  complete. 
The  memory  of  the  period  of  disease  is  generally  extinct 
or  very  imperfect. 

Recovery  may  be  aided  by  good  food,  wine,  beer,  iron, 
etc.  Careful  attention  to  the  skin,  lukewarm  baths,  and 
keeping  the  body  warm  in  bed  also  act  favorably. 

A  rarer  termination  is  that  of  permanent  dementia,  and 
this  is  similar  to  that  observed  after  other  psychoses.  In 
this  event  the  grave  turning-point  will  be  recognized  by 
increase  in  the  bodily  weight  while  the  other  conditions 
remain  the  same.  It  is  not  always  easy,  when  the  period 
of  observation  is  short,  to  distinguish  it  from  severe  mel- 
ancholia.     But  the  consideration  of  the  causes  and  the 


HANDBOOK  OF  INSANITY. 

KIRCHHCFF. 


Plate  VI 


DESCRIPTION  OF  PLATE  VII. 

MOBILE    DEMENTIA. 

At  first  sight  we  will  not  recognize  the  expression  of  dementia 
in  the  adjacent  pictures,  although  the  individuals  were  completely- 
demented.  Hence  the  pictures  show  the  important  fact  that  the 
facial  expression  of  the  insane  very  often  does  not  correspond  to 
the  mental  condition.  This  shows  that  the  actions,  speech,  and 
demeanor,  past  and  present,  must  all  be  compared. 

The  girl  shown  in  the  two  upper  pictures  was  formerly  maniacal ; 
her  play  of  features  is  not  volitional.  She  exhibits  great  bodily 
restlessness,  with  a  tendency  to  striking  and  biting ;  she  sings, 
hisses,  threatens,  but  the  words  employed  present  no  coherence. 

The  expression  of  the  woman  in  the  lower  picture  is  produced 
voluntarily  and  is  due  to  a  theatrical  tendency.  The  mouth  and 
eyes  are  wide  open,  hence  the  forehead  is  wrinkled  and  the  eye- 
brows arched  ;  the  elevated  and  extended  hands  aid  in  producing 
an  expression  of  astonishment  and  fright.  The  much  more  violent 
affects  of  profound  mental  distress  and  horror  are  expressed  in  a 
similar  way,  but  they  also  exhibit  rectangular  furrowing  in  the 
middle  frontal  region  and  various  vasomotor  signs,  such  as  dilata- 
tion of  the  pupils,  acceleration  of  respiration,  etc.  All  these  signs 
are  absent  in  our  patient. 

The  picture  of  the  man  also  shows  a  purposeless  play  of  the  facial 
muscles.  The  upper  half  of  the  right  side  of  the  face  exhibits  mel- 
ancholic elements ;  the  right  half  is  grinning. 


DESCRIPTION  OF  PLATE  VIII. 

DULL    DEMENTIA. 

The  adjacent  pictures  also  contain  elements" of  melancholic  forms 
of  expression,  because  they  repi-esent  terminal  stages  of  melancholic 
forms  of  disease,  although  the  patients  are  completely  demented. 
The  pictures  of  the  woman  were  taken  after  an  interval  of  several 
weeks  and  show  very  well  the  rigid,  stereotyped  expression  of  a 
melancholia  which  has  passed  into  dementia. 

The  wrinkled  brows  of  the  young  man  on  the  left  also  indicate 
previous  melancholic  depression  ;  he  has  been  demented  for  years 
and  sits  mute,  but  occasionally  tears  his  hair  and  picks  off  the  skin 
of  the  face  and  scalp ;  this  is  shown  by  the  light  spots  and  the  bald 
head. 

The  young  man  on  the  right  is  also  mute ;  his  previous  history 
is  obscure.  His  general  bearing  and  gait  seem  to  indicate  increased 
self-esteem,  and  this  does  not  appear  to  be  contradicted  by  the 
facial  expression.  But  as  a  matter  of  fact  he  is  completely  de- 
mented and  makes  terrible  grimaces.  He  has  become  a  veritable 
expert  in  movements  of  the  mouth  and  displacement  of  the  integu- 
ment of  the  forehead.  All  the  movements  are  made  in  a  quiet, 
dignified  manner,  while  the  hands  are  crossed  on  the  back  or  the 
arms  folded  on  the  chest. 


HANDBOOK  OF  INSANITY. 


KIRCHHOFF. 


Plate  VII 


''-^I^V&v^fc  ■■**&&* 


SECONDARY   DEMENTIA.  261 

distinct  melancholic  depression,  the  disordered  sleep,  and 
the  occasional  manifestations  of  the  vivid  mental  life  will 
soon  enable  us  to  arrive  at  a  diagnosis. 

The  second  form  of  dementia,  so-called  secondary  de- 
mentia, is  a  terminal  condition  of  other  mental  diseases 
and  is  very  frequent.  When  the  highest  grades  are 
reached  it  usually  remains  permanent,  but  it  may  also 
undergo  notable  improvement,  although  it  never  disap- 
pears entirely.  It  is  divided  into  agitated  and  apathetic 
dementia. 

In  agitated  dementia  there  is  more  or  less  excitement. 
The  patient  exhibits  a  disconnected  frivolous  dotage  and 
mobile  grimaces.  We  find  a  stupid  play  of  expression, 
without  vivid  affect :  stupid  smiles  or  tearful  grimaces,  a 
childish,  foolish,  stupid  demeanor.  The  patients  run  to 
and  fro,  laugh,  dance,  and  sing;  some  are  constantly 
cheerful,  others  are  tearful,  others  exhibit  alternations  if 
disturbed  in  any  movement.  Many  perform  monotonous 
movements  in  endless  repetition,  sometimes  of  a  very 
complicated  character,  for  example,  grasping  the  right 
ear  with  the  left  hand  and  at  the  same  time  touching  the 
nose  with  the  right  hand ;  brushing  and  picking  at  the 
clothes,  etc.  It  is  possible  that  these  movements  were 
originally  the  result  of  delusions  or  hallucinations,  but 
now  they  are  independent.  They  are  the  direct  results, 
without  psychical  intermediation,  of  the  irritative  condi- 
tion of  the  cortex,  which  is  supposed  to  result  from  pro- 
gressive destruction  of  the  cerebral  tissue. 

Mobile  dementia  is,  clinically,  often  a  transition  to  the 
apathetic  form,  into  which  it  generally  passes  after  it  has 
lasted  a  sufficiently  long  time.  Despite  their  outward 
activity  the  patients  have  no  comprehension  of  questions. 
Uncleanliness  is  the  rule.  The  restlessness  occasionally 
persists  at  night ;  the  nutrition  then  suffers  and  does  not 
improve  until  the  transition  into  apathetic  dementia  takes 
place. 

Finally,  the  highest  degree  of  dementia  is  found  in  the 
apathetic  form.     This  is  mental  death.     It  might  be  sup- 


262  '  HANDBOOK   OF   INSANITY. 

posed  that  we  had  to  deal  with  beings  deprived  of  the 
brain  did  not  the  continuance  of  the  vegetative  functions 
testify  to  the  activity  of  the  lower  centres.  All  indepen- 
dent action  is  wanting.  The  patients  must  be  fed,  washed, 
held  when  attending  to  the  wants  of  nature.  With  ex- 
pressionless features  and  relaxed  muscles  they  sit  immov- 
able for  days  in  the  position  in  which  they  have  been 
placed.  Saliva  flows  from  the  mouth,  mucus  from  the 
nose,  the  urine  escapes  into  the  clothes,  and  the  fseces  are 
passed  unnoticed.  Speech  ceases,  and  merely  inarticulate 
cries  may  now  and  then  accompany  a  temporary  excite- 
ment ;  sometimes  the  patients  may  bite  and  scratch  when 
they  are  stimulated.  The  movements  performed  are  slow, 
the  muscles  are  flabby.  Nutrition  is  often  excellent,  and 
great  obesity  may  develop.  This  condition  may  last  for 
years  before  death  ensues.  As  a  general  thing,  however, 
death  follows  soon  as  the  result  of  the  poor  circulation, 
pneumonias,  and  exhausting  diarrhoeas. 

The  sole  treatment  consists  of  careful  nursing.  As  not 
a  few  cases  of  secondary  dementia  show  no  anatomical 
changes  in  the  brain,  and  as  these  are  the  cases  which, 
as  a  rule,  end  in  death  with  comparative  rapidity,  the 
pathological  changes  found  in  another  series  of  cases  must 
be  regarded  as  results  rather  than  as  causes  of  this  form  of 
dementia.  The  most  frequent  change  is  general  atrophy 
of  the  brain,  with  dilatation  of  the  ventricles ;  meningeal 
opacities  and  thickenings  are  less  frequent.  The  micro- 
scopical changes  consist  of  accumulation  of  fat  and  pig- 
ment in  the  ganglion  cells  and  dilatation  of  the  capillaries, 
with  accumulation  of  granules  in  the  sheaths.  It  is 
probable  that  the  number  of  negative  cases  would  be 
diminished  if  we  excluded  the  milder  cases  of  mental 
weakness.  Clinically,  imbecility  is  also  entirely  different 
from  dementia,  however  numerous  the  transitions  may  be. 

B.    SENILE    DEMENTIA. 

Senile  dementia  is  a  mental  disorder  which  is  accom- 
panied by  diffuse  atrophy  of  the  brain,  and  is  either  the 


SENILE   DEMENTIA.  263 

termination  of  a  melancholia  or  mania  acquired  during 
old  age,  or  it  appears  from  the  start  as  a  condition  of 
mental  weakness.  The  latter  form  will  first  be  discussed. 
It  is  associated  with  the  physiological  involution  of  the 
brain,  and  hence  there  are  numerous  transitions  between 
the  diminished  mentality  of  old  age  and  true  dementia. 
In  some  cases  prodromata  are  almost  entirely  wanting, 
but  usually  the  dementia  develops  gradually. 

Forgetfulness  first  becomes  noticeable.  Memory  for  re- 
cent events  first  fails,  while  the  memories  of  early  childhood 
may  be  even  more  vivid  than  usual.  A  certain  loquacity 
and  tendency  to  diffuse  repetition  of  the  same  stories  may 
increase  this  appearance,  but  these  very  repetitions  show 
that  memory  is  impaired.  If  this  forgetfulness  is  noticed 
by  the  patient  it  leads  him  to  make  false  statements  as  a 
sort  of  excuse  for  his  conduct.  He  becomes  irritable  and 
mistrustful ;  if  he  mislays  anything,  he  maintains  that  it 
has  been  stolen  or  mislaid  by  others.  The  same  mistrust 
induces  him  to  conceal  things,  in  order  to  guard  against 
robbery.  He  often  does  not  know  his  own  property  and 
appropriates  that  of  others,  without  any  special  tendency 
to  theft.  He  exhibits  a  restless,  busybody  manner.  By 
day  and  night  he  rummages  among  old  papers  and  other 
objects.  A  brief  tired  feeling  often  overcomes  him  during 
the  day,  in  the  midst  of  a  conversation  or  during  a  meal. 
He  pockets  useless  objects,  valuables,  tools,  stumps  of 
cigars,  etc.,  and  offers  violent  resistance  when  an  attempt 
is  made  to  take  them  away.  His  restlessness  drives  him 
into  the  street,  where  he  makes  senseless  purchases,  and 
only  returns  home  by  accident  or  after  going  a  round- 
about way. 

Soon  the  patient  mistakes  windows  for  doors  or  may 
injure  himself  severely ;  he  handles  dangerous  articles  re- 
gardless of  danger  to  himself  or  others.  Many  commit 
gross  offences  against  good  manners  and  morals,  make 
sexual  attacks,  especially  upon  children.  The  sexual 
sense,  in  general,  is  intensified  and  the  impossibility  of 
normal  gratification  leads  to  many  immoral  acts. 


264  HANDBOOK   OF   INSANITY. 

Obstinacy,  vanity,  and  great  selfishness  are  added  to 
these  symptoms ;  resistance  to  impracticable  plans  rouses 
the  temporary  anger  of  the  patient.  The  extinction  of 
emotional  life  is  shown  in  the  lack  of  sympathy  toward 
his  family ;  any  affects  which  may  be  noticed  are  super- 
ficial. The  patient  often  fails  to  recognize  his  own  rela- 
tives and  forgets  their  names. 

At  this  time  the  anatomical  basis  of  the  morbid  process 
is  often  manifested  distinctly  by  slight  spasmodic  seizures, 
temporary  paralyses  of  single  nerves,  vertigo,  aphasic  dis- 
turbances. Remarkable  improvement  may  also  be  noticed, 
but  in  general  the  dementia  increases  progressively.  The 
patient  dresses  wrongly,  puts  his  legs  in  his  coat,  draws 
his  stockings  over  his  hands,  attends  to  the  wants  of  na- 
ture wherever  he  may  happen  to  be,  and  handles  the 
excrement. 

As  a  rule,  hallucinations  and  delusions  are  absent  in 
this  pure  form  of  dementia.  As  a  matter  of  course,  they 
may  be  present  when  the  condition  has  begun  with  melan- 
cholia or  mania.  A  feeling  of  loneliness  is  expressed; 
statements  are  also  made  that  nothing  exists,  that  the 
world  has  been  destroyed.  Definite  delusions  relating  to 
the  patient's  person  are  also  found,  such  as  that  he  is  not 
provided  with  food.  Imbecile  ideas  of  grandeur  are  most 
frequent,  such  as  revelling  in  gold,  which  is  looked  for  in 
the  hands  that  are  smeared  with  fseces.  There  are  rarely 
true  hallucinations,  usually  only  errors  of  observation. 

This  sad  picture  is  sometimes  relieved  by  the  retention 
of  some  pleasant  traits  of  the  former  life.  In  fact,  the 
childlike,  not  the  childish  and  foolish  elements,  may  pre- 
dominate. When  the  naughtiness  of  childish  conduct, 
uncleanliness,  and  violence  predominate,  the  interruption 
of  the  course  of  the  disease  by  apoplectic  attacks  may 
prove  a  real  relief  to  the  family.  Now  the  bodily  decay 
becomes  prominent ;  the  voracious  appetite  is  replaced  by 
anorexia,  often  on  account  of  digestive  disturbances  from 
overloading  of  the  stomach.  Insufficient  sleep  accelerates 
the  decay  of  the  vital  energy,  and  the  patient  is  compelled 


ANATOMICAL   LESIONS.  265 

to  take  to  bed.  Somnolence  may  next  develop.  On 
awaking  a  slight  excitement  may  begin,  but  finally  the 
word-images  are  lost  as  an  expression  of  ideas.  The  de- 
mentia is  gradually  shown  more  and  more  in  the  expres- 
sion, and  apathetic  dementia  is  often  the  termination 
unless  death  results  from  some  bodily  disease,  such  as 
pneumonia  or  intestinal  catarrh.  Death  often  results 
from  simple  loss  of  vitality.  The  extensive  calcification  of 
the  arteries  which  accompanies  the  disease  is  also  shown 
by  the  pulsus  tardus.  Irregularity  and  changes  in  the 
size  of  the  pupils  are  often  observed.  Other  motor  dis- 
orders, such  as  asymmetry  of  the  face,  tremor  of  the 
limbs,  and  especially  of  the  muscles  of  speech,  are  not 
uncommon. 

The  disease  rarely  develops  before  the  age  of  sixty  years ; 
in  the  few  cases  which  begin  between  the  ages  of  fifty  and 
sixty  years,  premature  senility  is  manifest.  The  disease 
generally  lasts  several  years,  in  rare  cases  only  a  few 
weeks. 

Treatment  can  effect  little.  The  main  elements  are 
good  food,  stimulation  of  the  circulation,  cleanliness,  and 
nursing.  Restlessness  at  night  is  relieved  by  light  beer 
and  wine  and  by  narcotics,  such  as  opium  and  morphine. 
Chloral  hydrate  is  a  dangerous  remedy  on  account  of  the 
brittle  condition  of  the  vessels  and  the  senile  changes  in 
the  heart. 

The  anatomo-pathological  changes  are  important.  The 
parietal  bones  are  often  very  thin,  occasionally  transparent 
from  disappearanc  of  the  diploe.  Marked  thickening  may 
be  observed  in  other  places.  Extensive  pachymeningitic 
deposits,  adhesions  of  the  dura  to  the  skull,  and  hsema- 
tomata  are  frequent.  There  is  an  excess  of  serum  in  the 
dural  cavity.  The  pia  mater  is  often  thickened  and 
opaque  and  contains  calcareous  plates  and  large  Pacchio- 
nian bodies.  The  size  of  the  brain  is  diminished,  its 
weight  lessened,  the  fissures  gape,  and  the  convolutions 
are  narrow,  especially  in  the  frontal  lobes.  The  gray 
matter  of  the  cortex  is  atrophied  and  the  lamination  oc- 


266  HANDBOOK    OF   INSANITY. 

casionally  obliterated.  The  white  substance  is  ansemie 
and  there  is  often  distinct  atrophy  of  the  fibres,  with  in- 
crease of  the  neuroglia.  The  ventricles  are  dilated,  and 
there  are  occasional  spots  of  softening  in  the  cortex  and 
white  matter.  The  ganglion  cells  usually  exhibit  atrophy, 
fatty  degeneration,  and  accumulation  of  pigment.  Athe- 
romatous degeneration  of  the  vessels  is  frequent,  but  does 
not  always  extend  to  the  capillaries. 

C.    PARALYTIC   DEMENTIA. 

Paralytic  dementia  is  a  mental  disorder  which  is  char- 
acterized by  mental  weakness,  progressing  rapidly  to 
dementia,  and  is  regularly  associated  with  increasing 
motor  disturbances  and  vasomotor  paralyses.  The  clin- 
ical history  varies  greatly,  according  as  profound  affects 
with  delusions  are  present  or  not.  Most  frequently  there 
is  a  distinct  expansive  mood  during  a  certain  period  of 
the  disease ;  more  rarely  there  is  a  depressed  mood  or  a 
simple  demented  condition  without  affect.  We  will  first 
describe  the  first  and  more  typical  variety. 

Paralytic  dementia  is  attended  with  a  definite  anatom- 
ical change  in  the  brain;  it  is  mainly  a  disease  of  mature 
life  in  the  male  and  always  terminates  unfavorably. 

The  disease  never  begins  suddenly,  and  indeed,  as  a  rule, 
certain  morbid  signs  have  appeared  and  disappeared  for 
several  years.  At  first  the  disturbances  are  general  in  char- 
acter: general  malaise,  irritability,  frequent  headaches. 
The  pain  in  the  head  is  often  annular  or  consists  of  a  feel- 
ing of  pressure ;  sometimes  the  sutures  are  especially  sen- 
sitive. The  mood  is  irritated,  often  almost  melancholic, 
and  is  usually  out  of  harmony  with  the  existing  circum- 
stances and  with  the  mood  of  healthy  days.  Hence  the 
disease  has  been  called  a  progressive  change  of  character, 
accompanied  at  an  early  period  by  certain  signs  of  mental 
weakness.  The  latter  feature  is  shown  most  distinctly  by 
the  great  forgetfulness  and  the  readiness  with  which  ex- 
haustion occurs  after  mental  work.     At  times  the  patients. 


PRODROMAL    SYMPTOMS.  267 

cannot  bring  themselves  to  do  any  work  at  all.  The 
weakness  of  memory  affects  chiefly  the  events  of  the 
present  and  the  immediate  past.  The  ability  to  retain 
new  impressions  is  lost ;  a  visit,  a  meal,  a  matter  of  busi- 
ness are  forgotten  at  once.  In  comparison  with  what  the 
patient  is  still  able  to  do,  his  exhaustion  appears  inexpli- 
cable to  his  family,  and  they  reproach  him  for  his  want 
of  energy.  All  mental  work  which  is  attended  by  inde- 
pendent decisions  becomes  more  and  more  impossible, 
while  mechanical  routine  work  can  be  performed  for  some 
time  longer,  although  carelessness  and  omissions  are  early 
noticeable.  At  the  same  time,  or  soon  afterward,  the  pa- 
tient is  annoyed  by  more  violent  headache  with  scotomata 
and  pains  in  the  eyes  and  tinnitus  aurium ;  his  interpre- 
tation of  the  present  now  becomes  inaccurate,  and  con- 
sciousness is  clouded  in  a  measure.  A  notable  improve- 
ment in  these  symptoms  now  takes  place,  as  a  general 
thing,  and  they  are  replaced  by  other  irritative  conditions ;, 
difficulty  in  breathing,  fulness  in  the  stomach,  pains  in 
the  limbs,  and  hence  insufficient  sleep.  Finally,  slight 
disturbances  of  individual  motor  nerves  are  found  very 
often  as  prodromata  of  typical  paralytic  dementia.  Oc- 
casional awkward  movements  of  the  tongue,  temporary 
twitchings  of  the  face,  unilateral  facial  paresis,  or  tremor 
of  the  limbs,  are  observed  even  at  this  time,  so  that  all 
the  signs  of  the  fully  developed  disease  are  indicated,  viz. , 
beginning  mental  weakness,  vasomotor  changes,  and 
motor  disturbances.  The  combination  of  these  signs  is 
important  in  distinguishing  dementia  paralytica  from 
neurasthenic  conditions,  in  which  mental  weakness  is 
wanting.  Moreover,  the  paralytic  dement  notices  very 
little  or  nothing  of  the  change  in  his  mental  condition, 
while  the  neurasthenic  makes  this  change  the  central 
point  of  his  mental  interest. 

While  the  disease  progresses  in  every  direction,  the 
blunting  of  the  feelings  deserves  special  mention.  The 
indifference  to  sad  and  joyful  events  within  the  family 
circle  is  especially  striking  if  the  patient  has  been  a  man 


268  HANDBOOK   OF  INSANITY. 

of  delicate  feelings.  Corresponding  losses  are  also  ob- 
served in  the  aesthetic  domain.  The  patient  loses  all 
interest  in  art,  science,  and  other  higher  intellectual  pur- 
suits, and  exhibits  a  striking  preference  for  coarse  sensual 
pleasures.  True  irritative  phenomena,  with  excited  or 
depressed  mood,  are  still  absent,  while  distinct  mental 
weakness  and  helplessness  are  found  in  all  psychical  pro- 
cesses, and  the  inability  to  concentrate  the  attention 
becomes  greater.  The  patient  appears  very  absent-minded, 
hardly  notices  what  is  going  on  about  him,  or  his  percep- 
tions lack  their  former  clearness.  The  uncertain  inter- 
pretation of  external  impressions  increases  the  weakness 
of  memory  and  unites  with  it  to  form  a  condition  of  dull 
brooding.  If  the  mind  is  somewhat  clearer,  the  deficiency 
of  judgment  becomes  so  much  more  striking  during  con- 
versation. Even  at  this  time  fantastic  additions  are  made 
to  stories  if  their  reality  is  disputed,  or  violent  statements 
are  made  as  an  expression  of  the  irritable  mood  of  the 
patient  who  has  been  detected  in  exaggerations. 

Perversities  of  action  now  become  more  prominent,  par- 
ticularly in  aesthetic  matters.  Gross  offences  against  cus- 
toms, laws,  and  morals  accumulate.  The  patients  begin 
to  drink  a  good  deal,  frequent  low  resorts,  address  women 
on  the  street  in  the  most  vulgar  manner.  In  society,  upon 
the  street,  or  in  front  of  the  open  window  they  expose 
their  genitals  without  noticing  the  impropriety.  Money 
is  wasted  in  the  most  extravagant  manner  and  senseless 
purchases  are  made.  When  their  money  is  wasted  debts 
are  contracted,  but  their  payment  is  entirely  forgotten. 
All  these  acts  are  attended  with  an  indescribable  equa- 
nimity, which  is  undisturbed  by  any  remonstrance,  simply 
because  the  events  do  not  reach  the  level  of  fully  con-, 
scious  judgment.  These  symptoms  may  exist  without 
marked  excitement  or  distinct  delusions,  so  that  the  pa- 
tients create  the  impression  of  drunkards.  This  is 
understood  so  much  more  readily  in  view  of  the  fact  that 
very  small  amounts  of  alcohol  suffice  to  excite  the  patient. 
-But  the  same  conduct  often  continues  long  after  the  period 


CHANGES   OF   MOOD.  269 

of  action  of  the  alcohol,  and  the  internal  excitement  is 
now  manifested  by  the  tendency  to  make  numerous  plans, 
often  merely  by  the  repetition  of  visits  to  friends  and 
acquaintances,  or  even  to  strangers. 

At  this  stage  we  find  quite  constantly  a  slight  obstruc- 
tion to  the  tongue,  which  becomes  more  distinct  when  the 
excitement  increases,  together  with  slight  associated 
movements  of  the  facial  muscles  in  speaking  and  slight 
tremor  of  the  hands.  This  is  sometimes  associated  with 
vertigo  or  spasmodic  attacks,  after  which  the  patients 
very  often  recover  somewhat  of  their  mental  tone.  In  an 
equal  number  of  cases,  however,  these  mild  attacks  are 
the  boundary  between  the  complete  psychosis  and  its  pro- 
dromata.  At  the  close  of  the  prodromal  period  the  mood 
is  extremely  capricious,  passing  directly  from  cheerful 
carelessness  to  morose  tearfulness  and  reckless  anger. 
This  irritability,  on  the  one  hand,  and  the  ready  exhaus- 
tion, on  the  other  hand,  show  most  clearly  the  mental 
weakness  in  the  condition  of  the  paralytic,  although  it  is 
unnoticed  by  the  patient. 

It  is  an  astonishing  feature,  however,  that  the  patient's 
conduct  is  wrongly  interpreted  for  a  long  time  by  those 
around  him.  Thus,  officers  still  continue  in  service  de- 
spite gross  carelessness  and  irrational,  often  inhuman 
treatment  of  their  soldiers,  and  officials  and  merchants 
are  regarded  as  merely  nervous  despite  the  greatest  dis- 
order in  their  papers.  It  is  only  when  distinct  delusions 
and  other  symptoms  become  marked  or  some  single  action 
brings  the  patient  in  conflict  with  the  criminal  law  that 
the  eyes  of  the  family  are  opened. 

Although  the  variability  of  the  mood  often  leads  to  sad 
notions,  they  are  rarely  prominent  for  a  long  time ;  but  the 
delusions,  which  soon  make  their  appearance  in  an  expan- 
sive form,  are  preceded  for  a  longer  or  shorter  period  by 
depressed  delusions.  The  latter  will  be  considered  in  de- 
tail in  the  discussion  of  the  depressive  form  of  the  disease. 
Here  we  will  at  once  discuss  the  ideas  of  grandeur  which 
develop,  usually  after  a  depressed  interval. 


270  HANDBOOK   OF   INSANITY. 

As  a  matter  of  course,  the  transition  from  the  prodro- 
mata  to  the  complete  disease  is  not  abrupt,  and  at  first 
we  find  only  indications  of  the  ideas  of  grandeur.  The 
restless  patient  becomes  enterprising  and  eager  to  improve 
things.  He  determines  to  change  his  occupation  and  to 
instruct  the  authorities  in  their  duties.  He  telegraphs  here 
and  there,  and  buys  things  in  the  most  foolish  and  extrava- 
gant manner,  for  example,  a  dozen  coaches  and  twenty 
parrots,  etc.  So  long  as  he  is  not  restrained  the  expan- 
sive ideas  are  manifested  by  such  acts,  but  when  restraint 
is  exercised,  as  in  an  asylum,  the  mental  weakness  appears. 
Instead  of  then  attempting  to  gain  his  desires  forcibly,  he 
is  content  to  revel  in  the  increased  flight  of  his  ideas. 
There  is  a  remarkable  similarity  in  the  contents  of  these 
ideas,  varying  slightly  with  the  social  position,  education, 
race,  sex.  Men  speak  of  size,  riches,  power,  and  glory; 
women  of  dress,  love,  and  children.  The  patients  are 
colonels,  generals,  princes,  kings,  and  are  called  to  lead 
the  nation,  the  world,  the  universe.  They  own  castles 
and  palaces  whose  walls  are  made  of  gold.  They  possess 
enormous  treasures,  beginning  with  hundreds  of  thousands 
and  soon  reaching  millions  and  billions.  Their  liberality 
is  unbounded  and  they  dispense  titles,  offices,  and  treasures 
to  their  relatives,  friends,  and  others.  The  patient  often 
has  no  distinct  notion  of  the  monstrous  character  of  his 
statements,  but  much  of  it  is  mere  boasting ;  this  is  shown 
especially  by  the  facility  with  which  the  exaggerations  are 
increased  when  doubt  is  thrown  upon  them.  The  patient 
is  fond  of  bragging,  and  if  he  has  just  given  away  thou- 
sands and  more  is  asked,  he  is  at  once  willing  to  give  mill- 
ions. But  he  rapidly  forgets  this,  and  may  state  that  a 
present  of  a  few  dollars  is  in  itself  a  liberal  one.  It  is 
also  surprising  when  we  find  that  such  a  boaster  himself 
begs  for  a  nickel  or  is  happy  at  the  gift  of  a  cigar.  Im- 
mediately afterward  he  says  that  he  is  the  emperor  or 
God,  that  he  understands  all  the  languages  of  the  world. 
When  asked  to  speak  in  a  foreign  language,  he  declares 
that  he  has  forgotten  it  or  makes  some  empty  excuse. 


IDEAS   OF   GRANDEUR.  271 

He  does  not  attempt  to  combine  his  delusions  into  a 
system,  and  the  ideas  of  grandeur  are  loosely  strung  to- 
gether; fanciful  additions  to  his  thoughts  are  usually 
wanting,  and  frequent  conversations  almost  always  reveal 
a  great  poverty  of  thought.  The  monotony  of  the  con- 
stantly recurring  monstrosities  shows  the  mental  weak- 
ness. The  apparent  productivity  is  often  the  result  of  the 
questions  put  to  the  patient.  The  size  of  his  assumed  pos- 
sessions often  transcends  his  vocabulary,  and  he  is  com- 
pelled to  coin  words  in  order  to  describe  them.  The  boun- 
daries of  time  and  space  disappear,  the  laws  of  nature  and 
probability  are  transgressed  without  hesitation.  One  pa- 
tient possesses  one  hundred  elephants  with  which  he 
ploughs  the  land,  horses  that  play  ou  every  instrument  and 
speak  different  languages ;  he  builds  a  railway  of  emer- 
alds and  rubies  to  the  skies ;  he  lives  in  a  diamond  palace, 
from  which  roads,  made  by  himself,  lead  across  the  entire 
earth,  which  he  rules.  Contradictions  to  former  statements 
are  not  uncommon.  If  the  patient  attempts  to  assume  a 
dignified  appearance  or  majestic  walk,  this  is  often  at  vari- 
ance with  his  miserable,  uncleanly  exterior.  While  he 
invites  mankind  to  great  feasts  at  tables  miles  in  length, 
he  walks  about  in  torn  clothes  and  with  dirty  hands. 

The  direct  outcome  of  the  idea  of  grandeur  from  the 
morbid  processes  in  the  brain  is  sometimes  shown  when  a 
depressed  mood  appears  temporarily.  But  exaggeration 
remains  the  special  sign ;  the  patient  says  he  has  squan- 
dered billions,  must  remain  in  prison  for  thousands  of 
years.  Such  moods  are  often  associated  with  slight  at- 
tacks of  vertigo. 

Another  group  of  ideas  of  grandeur  refers  more  closely 
to  the  patient's  own  person  and  bodily  sensations.  These 
notions  often  become  more  prominent  when  the  height  of 
the  excitement  is  passed.  Everything  appears  rose-col- 
ored, he  is  young  and  beautiful,  is  strong  enough  to  over- 
come hordes  of  the  strongest  men.  He  has  an  iron  chest, 
can  fly  or  jump  over  church-steeples.  When  his  pupils 
are  examined,  he  maintains  that  they  are  three  yards 


272  HANDBOOK   OF  INSANITY. 

wide.  He  boasts  of  his  appetite,  eats  stuffed  elephants,, 
can  drink  a  thousand  bottles  of  champagne.  His  sexual 
desires  can  only  be  gratified  by  an  innumerable  number  of 
women.  Female  patients  give  birth  to  the  most  beautiful 
children,  all  twins  or  still  greater  number  at  a  birth. 
They  have  three  or  more  husbands.  In  general,  the  ex- 
pression of  ideas  of  grandeur  in  women  is  confined  within 
more  modest  bounds  than  in  men. 

Similar  ideas  are  entertained  with  regard  to  mental 
ability.  The  patient  is  a  poet  and  musician  of  the  first 
rank,  writes  all  the  law-books  of  the  world,  his  thoughts 
are  all  noble  and  great.  With  his  waking  thoughts  he 
mingles  the  fancies  of  his  dreams. 

Although  there  is  a  certain  monotony  in  the  repetition 
of  the  same  ideas  of  grandeur  within  definite  boundaries, 
there  is  within  these  limits  a  great  variety  of  ideas  which 
change  from  minute  to  minute.  Although  they  often  re- 
semble one  another  for  long  periods,  even  during  the 
entire  duration  of  the  disease,  there  are  many  in  which, 
for  example,  a  patient  who  first  called  himself  a  wealthy 
sovereign  afterward  proclaimed  himself  a  great  artist. 
Fixed  delusions  are  not  present,  but  certain  ones  predom- 
inate, around  which  other  fleeting  ones  spring  up  and 
disappear.  The  latter  often  lead  the  observer  to  suspect 
poetic  fancy  and  bright  thoughts,  but  repeated  observa- 
tion enables  him  to  recognize  the  dulness. 

Although  hallucinations  may  be  entirely  absent,  they 
are  not  very  rare  in  the  different  periods  and  forms  of  the 
disease.  In  the  expansive  form,  especially  in  the  period 
of  excitement  under  consideration,  visual  hallucinations, 
chiefly  oc<rur,  such  as  angels  and  glistening  shapes.  Au- 
ditory hallucinations  are  rare  and  the  increasing  dementia 
makes  them  more  indistinct. 

The  increasing  failure  of  memory  deserves  further  no- 
tice. All  measure  of  time  is  lost;  the  patient  does  not 
know  whether  he  has  been  in  the  asylum  for  days  or 
weeks  and  is  ignorant  of  the  day  of  the  week.  He  for- 
gets names,  gives  a  wrong  date  to  his  birthday. 


DESCRIPTION  OF  PLATE  IX. 

PARALYTIC  DEMENTIA. 

In  special  cases  this  form  of  disease  may  present  any  of  the  forms 
of  expression  shown  in  the  previous  plates,  but  the  most  important 
signs  are  the  paralytic  phenomena,  or  rather  the  enfeebled  use  of 
individual  groups  of  muscles.  Several  pictures  of  the  same  indi- 
vidual appeared  to  be  best  adapted  to  convey  an  idea  of  the  twitch  - 
ings  and  irregular  paresis. 

In  the  first  picture  the  man  consciously  sat  for  his  photograph 
and  therefore  assumed  a  comparatively  intent  expression.  His  at- 
tention was  then  diverted  and  he  was  directed  to  say  "  photography. " 
The  attending  difficulties  led  to  irregular  spasmodic  contractions  of 
the  muscles,  and  the  difficult  movement  of  the  mouth  is  shown  in 
the  picture.  The  distress  resulting  from  the  inability  to  articulate 
the  word  is  shown  by  the  rectangular  crossed  furrows  in  the  fore- 
head. There  is  also  a  decided  difference  between  the  two  sides  of 
the  face.  In  the  picture  to  the  right  the  right  eyebrow  is  more 
wrinkled,  the  left  eyebrow  is  more  elevated,  and  there  is  a  corre- 
sponding increased  furrowing  of  the  forehead.  The  third  picture 
shows  these  phenomena  to  a  less  extent,  but  there  is  more  marked 
paralysis  of  the  levator  palpebrarum  on  the  right  side. 

In  the  picture  of  the  girl  the  slight  ptosis  of  the  lids  is  bilateral. 
Otherwise  the  expression  of  her  face  is  perfectly  vacant.  The  ear 
exhibits  a  shrunken  hsematoma. 


HANDBOOK  OF  INSANITY. 

KIRCHHOFF. 


Plate  IX. 


DISORDERS   OF   ARTICULATION.  273 

Numerous  bodily  disturbances  also  occur,  usually  at  the 
same  time  as  the  psychical  symptoms,  sometimes  earlier, 
but  also  often  later.  They  belong  to  the  entire  clinical 
history,  but  for  the  sake  of  clearness  must  be  described 
separately. 

Speech  and  voice  are  first  affected.  Articulation  is  in- 
terfered with  by  tremor  and  irregular  twitchings  of  the 
muscles  of  the  face,  lips,  and  tongue.  The  tremor  begins 
generally  near  the  naso-labial  fold  and  in  the  upper  lip. 
The  originally  fibrillary  twitchings  are  seen  more  dis- 
tinctly when  the  patient  is  excited  or  begins  to  speak. 
After  a  few  words  have  been  spoken,  the  twitching  disap- 
pears for  a  few  minutes.  In  connection  with  other  sus- 
picious symptoms,  it  may  permit  a  very  early  diagnosis, 
as  it  is  rare  in  other  psychoses.  It  is  seen  occasionally  in 
melancholia,  more  often  in  neurasthenia,  and  may  also  be 
a  prodrome  of  bulbar  paralysis. 

Notable  differences  in  the  innervation  of  the  facial 
nerves  may  be  found  at  an  early  period.  The  two  halves 
of  the  face  become  dissimilar,  and  we  find  imperfect 
marking  of  the  grooves  in  whose  vicinity  twitching  of  the 
muscles  takes  place.  One  naso-labial  fold  is  shallow  or 
obliterated,  the  angle  of  the  mouth  is  lowered ;  this  side  of 
the  face  has  less  mimic  expression  and  its  contractions 
are  slow.  True  paralysis,  however,  does  not  exist,  and 
indeed  complete  paralysis  is  very  rare  at  any  period  of 
dementia  paralytica. 

The  movements  do  not  correspond  exactly  to  their  ob- 
ject ;  they  are  uncertain  and  irregular.  Hence  the  motor 
disturbances  are  most  marked  when  fine,  complicated 
movements  are  to  be  performed.  Thus,  long  before  paraly- 
sis of  the  lips,  tongue,  or  palate  is  noticeable,  we  find  a 
disturbance  of  speech,  due  to  insufficient  quickness  and 
accuracy  in  the  co-ordinated  contractions  of  the  groups  of 
muscles  emploj^ed  in  articulation.  The  speech  disturbance 
of  general  paresis  is  an  inability  to  combine  letters  into 
syllables  and  syllables  into  words — it  is  essentially  a  dis- 
order of  articulation,  but  also  of  co-ordination.  The  letters 
18 


274  HANDBOOK   OF   INSANITY. 

forming  a  syllable  are  properly  enunciated  singly,  but 
they  are  combined  with  difficulty.  This  is  also  true  of 
the  combination  of  syllables  into  words;  some  syllables 
are  omitted,  others  repeated,  others  placed  in  the  wrong 
position,  so  that  the  condition  has  been  called  syllabic 
stuttering.  During  the  development  of  these  disorders 
the  exhaustion  of  the  muscles  becomes  more  distinct  with 
their  repeated  action.  The  tongue  is  protruded  in  short 
jerks,  because  the  requisite  power  is  wanting  and  the 
patient  is  uncertain  with  regard  to  the  amount  of  force 
required.  Hence,  when  directed  to  protrude  the  tongue, 
it  is  only  advanced  to  the  lower  lip.  The  patient  then 
makes  the  queerest  attempts  to  protrude  it,  even  uses  the 
fingers  for  this  purpose ;  at  the  same  time  associated  move- 
ments occur,  such  as  wrinkling  of  the  forehead  and  open- 
ing of  the  eyes.  In  speaking,  the  final  syllables  suffer 
most.  The  indistinct  enunciation  of  syllables  may  be 
spasmodic,  as  in  stuttering,  or  a  slow  dragging  of  a  sylla- 
ble, as  in  scanning.  Certain  labials  and  hissing  sounds 
suffer  particularly,  the  mouth  being  opened  as  little  as 
possible ;  when  the  lips  are  pressed  together  too  forcibly, 
speech  may  be  entirely  abolished  for  a  time.  At  times 
we  hear  a  sudden  improper  accentuation  of  individual 
syllables  or  words. 

In  the  description  given  we  find  a  combination  of  sev- 
eral disorders  of  speech,  which  are  described  separately  as 
syllabic  stuttering,  stammering,  scanning,  bleating,  lisp- 
ing, hesitation,  and  tremor.  It  is  difficult,  however,  to 
make  such  sharply  defined  distinction,  especially  in  para- 
lytic dementia,  because  the  anatomical  changes  may  occur 
in  all  those  tracts  to  which  the  speech  disorders  may  be 
attributed.  These  domains  are  the  beginning  and  end  of 
the  cortico-bulbar  speech  tract;  in  the  cortex,  probably 
near  the  motor  centres  of  the  central  convolutions,  we  must 
look  for  the  co-ordination  of  speech  expressions,  in  the 
medulla  oblongata  for  the  formation  of  the  elements  of 
speech  (vowels  and  consonants).  As  the  anatomical 
changes  do  not  occur  uniformly  or  at  the  same  time  in  all 


PHONETIC   DISORDERS.  275 

these  tracts,  the  distinctions  between  the  various  speech 
disorders  are  partly  obliterated,  and  our  description  has 
been  confined,  therefore,  to  the  actual  facts  ordinarily 
observed.  But  the  more  the  disease  is  confined  to  the 
cortex,  the  more  distinct  becomes  the  disordered  co-ordi- 
nation of  the  word  as  a  unit  composed  of  elements  and 
syllables,  and  these  are  jumbled  up,  either  because  the 
sound  memories  are  vague  or  because  their  coaptation 
is  carried  out  improperly.  If  the  disease  has  developed 
in  the  medulla  oblongata,  we  find  the  interference  chiefly 
in  the  production  of  elements;  at  the  same  time  the 
movements  of  the  tongue,  cheeks,  and  lips  are  disturbed 
in  mastication,  deglutition,  whistling,  etc.  When  the 
disorder  is  mainly  in  articulation,  the  clinical  history  is 
closely  allied  to  that  of  numerous  other  diseases  of  the 
medulla,  such  as  multiple  sclerosis  and  true  bulbar  paraly- 
sis. Hence,  only  that  disorder  which  has  its  origin  in 
the  cortex  can  be  regarded  as  characteristic ;  in  a  few  pure 
cases  this  can  be  recognized  separately.  It  is  question- 
able, however,  whether  the  disturbance  described  as  thick 
speech  should  be  referred  to  the  cortex  or  the  medulla  ob- 
longata. The  phrases  "truly  rural,"  "national  intelli- 
gencer," and  the  words  "  electricity,"  "  initiative,"  etc.,  are 
especially  adapted  to  bring  out  the  speech  disturbances  in 
question. 

The  matter  becomes  still  more  complicated  when  pho- 
netic disorders  appear.  The  degree  of  tension  of  the  vocal 
cords  is  sometimes  permanently  impaired,  speech  becomes 
whispered,  monotonous,  lower  in  pitch.  Occasionally  the 
patient  becomes  hoarse  or  makes  improper  use  of  his  air 
supply  and  the  tension  of  the  vocal  cords.  For  example, 
if  the  first  sounds  were  too  loud  the  voice  soon  sinks  to  a 
whisper,  and  finally  the  breath  fails  completely.  The 
changed  timbre  is  especially  evident  in  singing.  All  these 
disturbances  depend  mainly  on  the  innervation  of  the  lar- 
yngeal muscles,  but  disturbed  mobility  of  the  velum  palati 
is  also  shown  by  a  nasal  voice. 

An  important  proof  of  the  speech  disturbance  of  para- 


276  HANDBOOK   OF   INSANITY. 

lytics  is  found  in  reading  aloud.  "Wrong  words  are  read, 
because  the  patient  either  mixes  up  the  syllables  of  the 
printed  words  or  replaces  the  words  by  others  which  are 
allied  in  meaning,  sound,  or  appearance.  At  the  same 
time  the  letters  composing  these  words  may  be  pronounced 
correctly,  but  difficult  words  are  articulated  by  the  intro- 
duction of  easier  letters.  There  are  also  cases  in  which 
the  latter  disturbance  of  articulation  is  absent  and  the 
pure  disorder  of  co-ordination  appears.  Syllables,  espe- 
cially terminals,  are  added  to  the  words  and  sentences  of 
the  text,  some  words  are  replaced  by  others  of  an  entirely 
different  meaning,  and  in  this  way  a  new  and  incoherent 
text  is  created.  Repetition  of  the  reading  brings  forth 
constantly  new  combinations  of  syllables  and  words  which 
only  possess  a  remote  resemblance  to  the  original.  At 
the  same  time  the  patient  thinks  he  has  read  correctly, 
although  he  fails  to  understand  the  text.  This  disorder 
in  reading  sometimes  precedes  that  in  speaking. 

We  must  now  consider  the  disorders  of  speech  which 
depend  upon  disease  of  other  parts  of  the  cortex.  Not  in- 
frequently we  observe  temporary  attacks  of  true  aphasia, 
consciousness  being  either  abolished  or  more  or  less  im- 
paired. These  are  due  to  circulatory  changes,  circum- 
scribed cedemas  in  the  cortex,  or  more  pronounced  changes 
in  the  ganglion  cells.  Such  conditions  often  follow  so- 
called  paralytic  attacks,  which  consist  essentially  of  spas- 
modic motor  disturbances  with  impairment  of  conscious- 
ness. For  weeks  the  patient  may  be  unable  to  find  the 
name  of  some  object  which  he  recognizes.  Or  there  may 
be  entire  loss  of  speech,  with  partial  comprehension  of  sur- 
rounding circumstances.  The  variability  in  these  symp- 
toms and  their  combination  with  the  peculiar  changes  of 
speech  which  we  have  already  considered  are  character- 
istic of  paralytic  dementia.  Aphasia  is  permanent  only 
in  focal  destructions  of  the  cortex — and  this  does  not  hap- 
pen in  typical  paresis — or  when  complete  dementia  abol- 
ishes speech.  Increasing  dementia  is  thus  the  last  cause 
of  speech  disturbance.     When  dementia  has  set  in   the 


PUPILLARY   SYMPTOMS.  277 

patient  fails  to  understand  language.  It  is  characteristic 
of  the  primordial  importance  of  speech  as  the  expression 
of  all  psychical  processes  that  even  in  the  majority  of 
cases  of  focal  aphasia  intelligence  gradually  suffers,  par- 
ticularly because  diffuse  changes  occur  around  the  focal 
lesion  and  the  connections  with  other  parts  of  the  brain 
are  thus  implicated.  Inasmuch  as  paralytic  dementia  is 
a  diffuse  affection  of  the  cortex,  it  is  evident  that  its  co- 
ordinatory  and  aphasic  speech  disturbances  must  be  inti- 
mately associated  with  increasing  dementia. 

A  few  words  may  be  devoted  to  the  disorders  of  the 
contents  of  speech.  The  patients  indulge  in  circumlocu- 
tory expressions,  use  fanciful  self-made  words  and  terms 
of  expression,  and  return  to  the  grammatical  construction  of 
the  days  of  childhood.  Sometimes  the  patient  talks  as  if 
he  were  embarrassed,  but  as  this  develops  during  the 
course  of  the  disease,  it  may  be  assumed  to  be  the  result 
of  organic  causes.  Sudden  interruption  of  a  sentence, 
however,  may  simply  mean  that  the  demented  patient  is 
incapable  of  completing  the  line  of  thought. 

We  now  turn  to  the  disorders  of  other  motor-cerebral 
nerves  which  are  not  concerned  in  speech.  Pupillary 
symptoms  are  very  important,  but  only  when  they  have 
developed  during  the  disease,  and  other  causes  may  be  ex- 
cluded. For  this  reason  differences  in  the  size  of  the 
pupils  often  do  not  possess  very  great  significance ;  more- 
over, this  symptom  is  also  observed  in  other  psychoses. 
More  importance  attaches  to  frequent  changes  in  the  size  of 
both  pupils,  especially  during  excitement,  and  to  the  trans- 
fer of  dilatation  from  one  side  to  the  other.  In  the  latter 
event  the  disorder  is  undoubtedly  bilateral.  Unilateral 
dilatation  indicates  disturbed  innervation  on  this  side  only 
when  the  mydriasis  is  very  marked.  Otherwise  it  may 
be  due  to  contraction  of  the  other  pupil.  In  such  a  case 
the  disturbance  is  probably  present  in  that  eye  whose  iris 
is  less  freely  movable.  There  may  also  be  irregularities 
in  the  shape  of  the  pupil.  A  much  more  frequent  and 
important  sign  is  striking  and  permanent  contraction  of 


278  HANDBOOK   OF   INSANITY. 

both  pupils.  This  symptom  is  so  significant  that  when  any- 
mental  disturbance  has  been  demonstrated  it  almost  forces 
us  to  the  conclusion  that  it  will  develop  into  dementia 
paralytica.  Only  the  highest  grades  of  myosis  are  signif- 
icant, and  the  pupils  are  usually  only  as  large  as  the  head 
of  a  pin.  Vision  remains  unchanged.  It  is  worthy  of 
notice  that  this  marked  myosis  is  also  observed  when  dis- 
ease of  the  spinal  cord  is  absent.  Shading  or  illumination 
of  one  or  both  eyes  is  often  unable  to  produce  a  change  in 
the  size  of  one  or  both  pupils,  while  they  react  to  accom- 
modation. Hence,  there  is  reflex  rigidity  of  the  pupils 
with  retained  accommodation  mobility.  This  phenom- 
enon is  also  tolerably  frequent  in  dilated  or  moderately 
dilated  pupils. 

Very  pronounced  and  permanent  mydriasis  usually  ap- 
pears only  toward  the  end  of  the  disease. 

Slight  paralyses  of  individual  ocular  nerves,  especially 
the  abducens  or  a  branch  of  the  motor-oculi,  often  pre- 
cede the  disease  for  years.  The  resulting  diplopia  dis- 
appears, as  a  rule,  after  it  has  lasted  for  several  months. 
Temporary  nystagmus  and  spasm,  more  frequently  ptosis 
of  one  or  both  lids,  are  also  observed  occasionally.  Ac- 
cording to  recent  investigations  the  latter  symptom  has  a 
cortical  origin  in  the  lower  part  of  the  parietal  lobe. 

The  cortex  also  contains  a  centre  for  movements  of 
mastication,  and  it  is  therefore  very  probable,  in  the  ab- 
sence of  changes  in  the  medulla  oblongata,  that  the  symp- 
tom of  constant  violent  gritting  of  the  teeth  (very  fre- 
quently at  the  close  of  the  disease)  is  due  to  disease  of  the 
motor-cortical  region.  As  this  symptom  is  observed  in 
very  few  other  psychoses,  it  becomes  an  important  diag- 
nostic sign. 

Great  importance  attaches  to  disturbances  of  the  nerves 
regulating  the  movements  of  deglutition,  because  they 
give  rise  to  the  risk  of  "  swallowing  the  wrong  way. "  In 
this  way  the  danger  of  suffocation  often  arises  toward  the 
close  of  the  disease.  The  difficulty  of  deglutition  is  owing 
rather  to  awkwardness  than  to  true  paralysis  of  the  mus- 


GAIT.  279 

cles.  Such  patients  should  be  fed  very  slowly,  because 
they  generally  have  a  tendency  to  swallow  food  raven- 
ously. 

The  movements  of  the  a^ms  and  hands  become  awkward 
at  an  early  period,  and  the  patients  soon  become  unable  to 
thread  a  needle,  button  the  clothes,  etc.  This  awkward- 
ness (often  associated  with  rapid  exhaustion)  is  sometimes 
greater  on  one  side  of  the  body.  A  certain  degree  of 
stiffness  of  the  muscles  soon  adds  a  new  obstacle  to  the 
execution  of  intended  movements ;  tremor  at  such  times 
must  also  be  regarded  as  a  disturbance  of  innervation. 
The  incorrect  gauging  of  the  resistance  and  the  degree 
of  muscular  effort  to  be  employed  is  the  cause  of  irregular 
jerky  movements. 

This  is  shown  most  distinctly  in  writing.  Like  speech, 
the  writing  also  discloses  the  mental  condition  of  the  pa- 
tient. The  letters  themselves  are  uncertain,  the  strokes 
extend  beyond  the  normal  limits  and  run  in  curved  lines. 
Blots  are  numerous,  the  paper  is  soiled,  the  ink  is  partially 
rubbed  out  in  places,  the  lines  are  written  in  different 
directions,  sentences  are  interrupted,  punctuation  is 
senseless  or  entirely  wanting.  So  long  as  writing  is  at 
all  possible  the  tremulous,  uncertain  character  is  distinct. 
After  the  ability  to  write  is  entirely  lost,  the  patient  is 
greatly  embarrassed  when  requested  to  write,  and  usually 
makes  some  excuse,  such  as  "he  cannot  write  without 
glasses  or  does  not  feel  inclined  to  write."  In  some  cases, 
however,  writing  is  unaffected.  If  the  disorder  in  writing 
precedes  speech  disturbances — and  this  is  quite  often  the 
case — it  forms  a  very  important  sign  in  the  recognition  of 
the  disease. 

Apart  from  the  complication  with  tabes  the  gait  may 
be  affected  to  a  notable  degree.  At  first  the  walk  may  be 
tolerably  rapid,  but  there  is  a  certain  weakness  of  the  in- 
dividual movements,  the  steps  are  short,  and  the  feet 
are  not  lifted  sufficiently,  so  that  the  patient  stumbles 
over  inequalities  in  the  ground  or  on  walking  upstairs. 
The  ataxic  gait  need  not  be  described  here.     When  lying 


280  HANDBOOK    OF   INSANITY. 

in  bed  the  legs  can  be  moved  freely  for  quite  a  long  time, 
but  gradually  the  movements  become  tremulous  and  jerky, 
slower  and  more  rigid,  until  finally  a  certain  rigidity  and 
tension  of  the  muscles  are  the  only  evidence  of  the  attempt 
at  motion.  It  is  very  often  found  that  every  attempt  to 
place  the  arms  or  legs  in  a  new  position  meets  with  in- 
creasing resistance.  We  must  then  ascertain  whether 
this  resistance  results  psychically  from  notions  of  dread 
and  fear  or  is  a  result  of  direct  irritation  of  the  brain. 
In  the  latter  event  the  tension  probably  persists  during 
sleep.  But  the  fear  which  is  occasionally  manifested  is 
less  a  psychical  cause  of  the  increasing  rigidity  of  move- 
ment than  an  involuntary  expression  of  the  dread  that  a 
movement  is  required  which  will  be  attended  with  pain 
on  account  of  this  tension  of  the  muscles.  In  some  cases, 
however,  the  fear  which  depends  upon  the  increased  cere- 
bral pressure  may  predominate  over  the  rigidity  which 
also  originates  in  the  cerebral  cortex.  The  patients  then 
resist  every  approach,  do  not  allow  themselves  to  be  dressed 
or  undressed,  press  the  jaws  together  with  unyielding  force 
when  food  is  offered;  they  often  retain  fecal  discharges 
for  several  days.  Such  rigidity,  which  may  subside  tem- 
porarily, must  be  distinguished  from  spasms  due  to  dis- 
ease of  the  lateral  columns  of  the  cord.  In  fact,  variations 
in  the  degree  of  disturbance  of  the  gait  are,  to  a  certain 
extent,  characteristic. 

The  lack  of  uniform  innervation  is  also  evident  in  the 
position  of  -the  trunk ;  the  body  is  held  obliquely  toward 
one  side,  backward  or  forward.  The  position  changes 
frequently,  but  becomes  somewhat  more  constant  when  it 
is  associated  with  the  so-called  paralytic  attacks. 

These  paralytic  attacks  are  very  frequent,  and  may  be 
apoplectiform  or  epilectiform.  They  are  found  among 
the  prodromata  of  the  disease;  the  "fainting  spells"  re- 
ported by  the  family  are  probably  of  this  character.  At 
a  later  period  they  become  more  distinct  as  apoplectic 
attacks,  the  patients  fall  to  the  ground,  and  the  ensuing 
unconsciousness   lasts  longer.      They  rarely   prove  fatal 


EPILEPTIFORM   ATTACKS.  281 

directly,  but  their  sequelae  often  terminate  in  death. 
They  differ  from  true  cerebral  hemorrhage  in  that  perma- 
nent severe  paralysis  is  wanting,  but  there  is  a  constant 
impairment  of  motion  in  certain  groups  of  muscles  on 
one  side  of  the  body.  The  rapid  course  of  such  attacks 
and  the  absence  of  post-mortem  findings  force  us  to  con- 
clude that  they  are  the  result  of  sudden,  circumscribed 
circulatory  changes  in  the  brain,  perhaps  followed  by 
oedema. 

The  epileptiform  paralytic  attacks  must  be  regarded  as 
the  results  of  direct  irritation  of  the  cortex.  The  attacks 
are  generally  preceded  by  greater  irrationality  and  in- 
creased difficulty  of  movement,  occasionally  by  increased 
psychical  irritability  and  a  feeling  of  vertigo.  The  patient 
suddenly  falls  to  the  floor  and  convulsions  set  in,  either 
general  or  unilateral.  In  a  few  cases  the  convulsion  at- 
tacks the  head,  limbs,  and  trunk  in  a  certain  order.  The 
unilateral  convulsions  often  extend,  in  a  little  while,  to  the 
rest  of  the  body,  thus  resembling  true  epileptic  seizures. 

The  spasms  are  sometimes  confined  to  one  side  of  the 
face,  or  this  is  associated  with  constant  movements  of  the 
tongue.  After  the  attack,  twitchings  of  certain  muscles 
of  the  face  or  arms  sometimes  continue  for  hours.  After 
complete  cessation  the  patients  are  very  confused  for  a 
long  time.  A  considerable  increase  of  mental  weakness  is 
noticed  almost  constantly,  and  the  dementia  often  develops 
suddenly  after  the  attacks.  They  may  also  be  followed 
by  disturbances  of  speech  and  hemiplegia,  but  these  gener- 
ally recover  in  great  part.  The  attacks  recur  at  irregular 
intervals  of  days,  weeks,  and  months,  and  very  rarely  are 
they  entirely  absent.  They  sometimes  occur  in  series; 
hundreds  of  attacks  have  been  observed  within  a  few  days, 
and  then  death  generally  follows.  This  termination  has 
also  been  observed  within  a  few  hours  after  a  few  attacks. 
They  may  also  be  followed  by  maniacal  excitement  or  the 
latter  may  take  their  place  as  a  psychical  equivalent. 
During  the  attacks  the  temperature  generally  rises,  and 
sometimes  exceeds  41°  C. 


282  HANDBOOK    OF   INSANITY. 

Disorders  of  the  bladder  and  rectum,  independent  of 
disease  of  the  spinal  cord,  are  due  to  insufficient  atten- 
tion on  the  part  of  the  patient.  Complete  paralysis  of  the 
sphincters  only  occurs  in  general  paralysis  attending 
spinal  diseases. 

Numerous  psychomotor  disorders  occur  as  irritative 
phenomena  during  the  course  of  the  disease.  For  exam- 
ple, slight  catalepsy  and  peculiar  postures  of  the  limbs. 
"We  also  find  useless  imperative  movements,  which  occur, 
however,  in  the  shape  of  co-ordinated  movements,  such  as 
clapping  the  hands,  picking,  rubbing.  These  may  also  be 
due  in  part  to  local  irritation  of  the  skin. 

Finally,  the  motor  disorders  of  dementia  paralytica  are 
often  associated  with  systemic  diseases  of  the  cord,  es- 
pecially tabes  and  .spastic  spinal  paralysis.  The  not 
infrequent  combination  of  tabes  and  paralytic  dementia 
compefs  us  to  assume  an  intimate  relation  between  them. 
These  cases  are  distinguished  from  simple  dementia  para- 
lytica by  the  distinct  sensory  symptoms,  the  ataxic  gait, 
Romberg's  symptom,  and  optic-nerve  atrophy.  It  is  not 
improbable  that  these  phenomena  are  associated  with  the 
extension  of  the  disease  to  the  occipital  cortex.  Descend- 
ing disease  of  the  lateral  columns  occurs  almost  constantly 
in  slowly  progressing  dementia  paralytica.  In  such  cases 
the  spastic  symptoms  are  much  more  permanent  and  pro- 
nounced than  in  other  cases. 

The  reflex  excitability,  which  is  occasionally  increased 
at  the  beginning,  diminishes  quite  constantly  toward  the 
close  of  the  disease.  If  the  reflexes  are  increased  in  com- 
plete dementia,  it  may  be  explained  by  the  abolition  of 
the  inhibitory  influence  of  the  brain.  But  diminution  of 
the  superficial  and  deep  reflexes  is  almost  always  associated 
with  disease  of  the  spinal  cord,  especially  tabes. 

Rare,  and  probably  accidental,  disorders  are  peripheral 
paralyses  due  to  a  neuritis.  The  observation  of  cases  of 
paralytic  dementia  which  followed  peripheral  paralyses 
has  led  to  the  suspicion  that  the  former  may  develop  from 


.ANAESTHESIAS.  283 

the  latter,  but  this  mode  of  development  has  not  been 
demonstrated. 

Neuralgias  are  frequent  not  alone  among  the  prodromata, 
but  also  during  the  disease.  They  are  perhaps  dependent 
on  meningitic  processes  or  upon  circulatory  disturbances 
in  the  brain  itself. 

This  is  true  of  anaesthesias  only  to  a  certain  extent.  Cer- 
tain anaesthesias  are  undoubtedly  due  to  cortical  lesions, 
but  these  are  confined  to  small  portions  of  the  body.  This 
occurs  when  the  parietal  cortex  is  involved,  and  the  mus- 
cular sense  seems  to  be  especially  affected.  But  as  anaes- 
thesia commonly  develops  only  in  the  later  period  of  the 
disease,  the  dementia  is  commonly  too  far  advanced  to  per- 
mit us  to  obtain  accurate  data  concerning  its  situation. 
Disorders  of  feeling  are  very  important,  however,  because 
they  may  be  the  cause  of  numerous  severe  injuries  and 
mutilations,  such  as  burns  from  cigars,  a  stove,  bites  in 
the  tongue,  etc.  Delusions  which  are  due  to  the  disorder 
of  sensation  increase  the  danger.  Mere  insensibility  of  a 
limb  may  induce  the  patient  to  regard  it  as  something 
foreign,  and  therefore  to  inflict  injury  upon  it. 

Occasional  losses  in  the  domain  of  the  special  senses  also 
depend  upon  the  extension  of  the  disease  to  the  posterior 
brain.  This  has  been  observed  more  accurately  in  regard 
to  the  sense  of  sight.  Such  symptoms  must  be  distin- 
guished, for  example,  from  those  which  result  from  atro- 
phy of  the  optic  nerve  in  tabes,  or  from  diseases  of  the 
eye,  especially  inflammations  of  the  retina.  We  refer  to 
disorders  of  vision  which  point  to  the  cortex  as  their  source 
on  account  of  their  unilateral  character.  The  color  sense 
may  be  impaired,  likewise  the  distinction  between  light 
and  dark.  The  various  forms  of  contraction  of  the  field 
of  vision  which  are  due  to  focal  lesions  may  occur  tem- 
porarily in  dementia  paralytica. 

It  is  also  very  probable  that  the  subjective  light  phe- 
nomena and  visual  hallucinations  which  are  observed 
occasionally  in  paralytics  are  the  result  of  irritative  con- 


284  HANDBOOK    OF   INSANITY. 

ditions  in  the  occipital  cortex.  Hallucinations  of  all  kinds 
may  also  occur  in  dementia,  but  they  are  rarer  than  in 
other  psychoses  and  have  less  influence,  on  account  of  the 
dementia,  upon  the  patient's  conduct. 

Vasomotor  disorders  are  of  great  importance  in  this  dis- 
ease. The  variable  character  of  many  of  the  mental  and 
bodily  symptoms  appeared  to  show  that  the  vasomotor 
system  is  the  first  to  be  implicated,  and  this  is  also  evident 
in  the  subsequent  course  of  the  disease.  The  pulse  is  fee- 
ble and  shows  that  the  walls  of  the  vessels  are  distended 
very  gradually.  Progressive  paralysis  of  the  entire  vaso- 
motor system  leads  to  temporary  complete  paralyses  in 
certain  parts.  These  include  vertigo,  apoplectiform  at- 
tacks, unilateral  sweating,  rush  of  blood  to  the  head  and 
face,  local  redness  of  the  skin — all  of  which  rapidly  appear 
and  disappear.  This  alternates  with  spasm  of  the  vesssels, 
shown  by  pallor  of  the  skin  and  a  feeling  of  coolness. 
Toward  the  end  of  the  disease  permanent  vasomotor  paraly- 
sis is  evinced  almost  constantly  by  the  cedemas  and  cyano- 
sis, especially  of  the  hands  and  feet.  Punctate  hemorrhages 
into  the  skin,  also  hemorrhages  from  the  internal  organs, 
particularly  the  bowels,  are  observed.  These  symptoms 
are  attributed  to  implications  of  the  sympathetic  nervous 
system  and  probably  are  due,  in  part,  to  a  direct  affection 
of  the  cerebral  cortex. 

Closely  related  to  the  vasomotor  changes  are  the  trophic 
disturbances,  but  we  must  be  careful  to  exclude  lesions 
which  result  from  external  injury.  The  most  important 
trophic  changes  are  the  othematoma,  fractures  of  the  bones, 
and  gangrene  from  pressure.  These  cannot  be  attributed 
solely  to  external  mechanical  influences,  such  as  a  blow  or 
pressure,  because  the  often  trivial  injury  could  not  pro- 
duce such  severe  effects  were  it  not  for  the  vasomotor  - 
trophic  basis. 

Respiration  is  usually  unchanged.  It  is  probable  that 
the  frequent  pneumonias  are  not  due  to  vasomotor  paraly- 
sis, but  that  they  are  "  foreign-body"  pneumonias. 

Dementia  paralytica  usually  runs  an  apyrexial  course, 


DEPRESSION   IN   DEMENTIA.  285 

and  the  bodily  temperature  may  not  be  raised  even  during 
inflammatory  complications.  On  the  other  hand,  disten- 
tion of  the  bladder  and  rectum  may  occasion  brief  pro- 
nounced rise  of  temperature.  When  the  disease  is  far 
advanced  the  temperature  often  falls  below  37°. 

We  will  now  turn  to  the  consideration  of  the  rarer 
depressive  form  of  general  paresis.  It  begins  with  the 
same  prodromata  as  the  already-described  expansive  form, 
so  that  it  is  only  recognized  by  the  constant  predominance  of 
melancholic  feelings  and  ideas.  Fear  and  delusions,  which 
are  perhaps  always  associated  with  conditions  within  the 
body,  always  possesss  a  monstrous  and  unmeasured  char- 
acter. Loud  outcries,  with  all  the  signs  of  inner  restless- 
ness, and  sudden  suicide  are  not  uncommon,  even  when  the 
dementia  is  comparatively  far  advanced.  If  the  affect  has 
subsided  and  the  mental  faculties  can  still  develop  ideas 
with  a  certain  connectedness,  we  find  simple  melancholic 
self- accusations,  mingled  with  depressed  feelings  con- 
cerning the  patient's  own  body.  Such  a  condition  of  con- 
sciousness may  long  be  concealed  beneath  a  rigid  bearing 
before  complaints  are  uttered.  Sometimes  these  are  uttered 
very  early  and  can  be  distinguished  from  simple  melan- 
cholia by  their  peculiar  monstrous  character,  apart  from 
the  other  symptoms  of  paralytic  dementia.  It  is  equally 
common,  however,  to  find  ideas  which  might  belong  to 
the  history  of  simple  melancholia.  In  other  cases  the 
patient  is  tormented  by  the  idea  that  he  has  contracted 
debts  of  hundreds  of  thousands  or  millions  of  dollars,  that 
he  has  been  converted  into  a  glass  house,  or  that  his  head 
or  brain  is  shrivelling  and  drying.  Surrounding  persons 
and  objects  may  also  appear  to  shrivel  until  the  very 
existence  of  life  is  denied.  Sometimes  the  mood  of  nega- 
tion is  shown  in  acts  rather  than  in  speech.  The  patients 
offer  resistance  to  everything  that  is  done  for  them,  spit 
out  the  food  that  is  placed  in  their  mouths,  tear  their 
clothes. 

We  have  already  seen  that  the  depressed  mood  some- 
times forces  its  way  into  the  expansive  mood.     If  this 


28G  HANDBOOK   OP   INSANITY. 

occurs  with  a  certain  regularity,  the  term  circular  form 
of  dementia  paralytica  is  applied,  but  such  a  condition  is 
rarely  observed  in  a  pronounced  form. 

If  delusions  and  material  changes  of  mood  are  wanting, 
then  dementia,  in  addition  to  the  other  signs  of  paresis, 
predominates  in  the  course  of  the  disease.  Impairment 
of  memory  and  of  psychical  functions  of  all  kinds  develop 
gradually  until  the  dementia  reaches  the  same  degree  as 
in  the  other  forms,  accompanied  by  all  the  bodily  disorders 
of  the  disease.  Hence  all  the  different  varieties  resemble 
one  another  completely  at  the  close  of  the  disease.  The 
latter,  so-called  demented  form,  is  found  with  comparative 
frequency  in  women.  These  patients  are  not  transferred 
so  frequently  to  asylums,  because  the  mental  signs  of  the 
disease  are  milder  and  lead  more  rarely  to  conflicts  with 
law  and  order.  In  many  of  these  cases  the  condition  is 
mistaken  for  a  long  time  for  neurasthenia.  It  develops 
at  a  comparatively  early  age,  sometimes  even  before  the 
thirtieth  year. 

The  course  of  paralytic  dementia  in  general  is  subject 
to  many  changes,  and  all  the  symptoms  of  the  disease  may 
disappear  so  completely  that  we  are  tempted  to  believe 
in  true  recovery.  After  a  time,  sometimes  even  after 
the  lapse  of  one  or  two  years  or  more,  more  severe  symp- 
toms reappear,  and  thus  confirm  the  progressive  character 
of  the  ailment.  But  as  a  rule  there  is  a  steady  increase 
of  the  dementia  as  well  as  of  the  motor  symptoms.  The 
duration  is  extremely  variable,  but  averages  about  three 
years.  In  elderly  people  and  in  women  the  duration  is 
longer.  If  dementia  predominates,  without  delusions  or 
affects,  the  course  is  also  much  prolonged  and,  according 
to  some,  may  extend  over  twenty  years.  Exceptional 
cases  run  their  course,  with  violent  symptoms,  in  a  few 
months  or  even  weeks.  These  galloping  cases  are  of  tenun- 
recognized  and  are,  perhaps,  sometimes  included  under  so- 
called  acute  delirium,  to  which  we  have  already  referred. 

It  remains  for  us  to  consider  the  termination  which  is 
common  to  all  forms  of  the  disease  unless  its  course  has 


TERMINATIONS.  287 

been  interrupted  by  severe  paralytic  seizures  or  diseases 
of  various  organs.  If  this  does  not  happen,  the  dementia 
constantly  increases  and  a  mere  vegetating  body  remains. 
Finally,  walking  becomes  impossible  and  the  hands  be- 
come incapable  of  independent  movement.  The  helpless 
patient  then  lies  in  bed,  passes  urine  and  faeces  involun- 
tarily. Slow  compression-gangrene  often  accelerates  the 
termination,  or  this  is  brought  about  by  some  complica- 
tion, such  as  pneumonia,  suffocation  by  food,  nephritis, 
etc.  If  the  patient  escapes  these  dangers  he  emaciates 
and  gradually  succumbs. 

At  the  beginning  of  quiet  dementia  and  after  the  affects 
have  subsided,  many  patients  acquire  a  temporary  obesity 
which  persists  so  much  longer,  the  slower  the  course  of 
the  disease.  Toward  the  end  of  the  disease  we  sometimes 
find  brief  periods  of  excitement,  and  certain  irritative 
symptoms,  such  as  grinding  of  the  teeth,  may  become 
prominent.  In  fact,  the  latter  symptom  may  persist  until 
death. 

Paralytic  dementia  terminates,  therefore,  in  death,  in- 
asmuch as  complete  recovery  and  the  very  slow  forms  are 
so  extremely  rare  that  they  need  hardly  be  considered  in 
prognosis.  Unless  the  fatal  termination  results  from  sui- 
cide, suffocation,  injuries,  paralytic  attacks,  compression- 
gangrene,  or  internal  diseases,  the  patients  die  from  gen- 
eral exhaustion.  But  with  careful  treatment  at  the  onset, 
improvement  or  retardation  of  the  course  of  the  disease 
may  be  effected  to  such  an  extent  that  the  patients  may 
remain  capable  of  mental  work  for  a  long  time.  Some 
observations  appear  to  show  that  remissions  are  only  last- 
ing in  the  expansive  form  of  the  disease  and  when  speech 
disturbances  are  very  slight  or  almost  absent,  while  the 
depressed  or  demented  forms  hardly  ever  present  such  im- 
provement. 

The  development  of  the  disease  is  favored  by  the  nox- 
ious influences  inherent  in  the  agitated  life  of  recent  times, 
especially  when  associated  with  want,  worry,  and  bodily 
excesses.     Hence  it  occurs  chiefly  in  men  of  mature  years. 


288  HANDBOOK    OF   INSANITY. 

The  disease  may  develop  between  the  ages  of  twenty 
and  sixty  years,  but  it  is  by  far  most  frequent  between  the 
thirty-fifth  and  forty-fifth  years.  Outside  of  this  period 
the  diagnosis  may  only  be  made  when  all  other  possibilities 
are  excluded.  Cases  have  been  reported,  however,  as 
early  as  the  age  of  twelve.  In  women  the  influence  of  the 
menopause  somewhat  extends  the  age  limit.  Females  are 
attacked  about  one-sixth  as  often  as  males.  Women  of 
the  higher  classes  rarely  suffer.  Military  officers,  mer- 
chants, firemen,  railway  and  telegraph  officials  suffer  in 
strikingly  large  numbers;  lawyers  and  physicans  are  also 
attacked  with  comparative  frequency.  Heredity  does  not 
play  so  important  a  part  as  in  other  psychoses,  and  the 
disease  is  much  more  often  acquired  from  mental  over- 
work. It  is  probable  that  syphilis  is  an  important  predis- 
posing cause,  but  when  severe  symptoms  of  syphilis  are 
still  present  the  signs  of  dementia  paralytica  are  not  typi- 
cal, as  we  will  see  later.  Alcoholic  excesses  alone  give  rise 
to  different  symptoms,  but  drink  combined  with  sexual 
excesses  very  often  result  in  typical  paresis.  Dementia 
paralytica  after  injuries  to  the  head  also  exhibits  some 
special  symptoms. 

The  microscopic  changes  in  the  brain  extend  at  the  same 
time  to  the  blood-vessels  and  the  interstitial  tissue,  and 
later  involve  the  entire  brain  substance.  In  the  vascular 
sheaths  are  found  red  and  white  blood  globules,  the  vessels 
are  filled  with  blood  and  often  bent.  Thickening  of  the 
wall  makes  the  vessel  narrower,  in  places  the  nuclear  pro- 
liferation in  the  sheaths  produces  a  nodule,  and  sometimes 
miliary  aneurisms  are  found.  In  other  places  connective- 
tissue  prolongations  sprout  from  the  sheaths  of  the  vessels. 
In  some  cases  the  disease  of  the  vessels  is  also  found  in 
other  organs. 

The  basement  substance  in  a  large  part  of  the  cortex 
contains  an  increased  number  of  nuclei.  In  addition,  we 
find  numerous  lymphoid  wandering  cells  and  connective- 
tissue  cells,  among  which  spider  cells  are  especially  prom- 
inent in  the  layers  of  the  cortex  and  in  the  white  matter. 


ANATOMICAL   CHANGES.  289 

Extensive  adhesions  of  the  meninges  to  the  surface  of  the 
brain  are  found  only  in  those  places  in  which  there  is  in- 
crease of  the  connective-tissue  cells,  and  a  condensation  of 
the  basement  substance  (so-called  sclerotic  atrophy) .  Such 
adhesions  are  found  frequently  but  not  constantly ;  they 
may  be  absent  in  slowly  progressing  cases  in  which  great 
thickening  of  the  meninges  has  occurred.  It  is  probable, 
indeed,  that  the  adhesion  is  only  temporary,  that  it  de- 
pends on  swelling  of  the  basement  substance  and  may 
disappear  with  it.  This  does  not  occur  until  shrinking  of 
the  entire  brain  tissue  has  set  in.  Perhaps  the  absence  of 
adhesions  may  also  be  due  to  mechanical  conditions,  inas- 
much as  variations  in  intracranial  pressure  will  affect 
chiefly  the  cortex.  This  may  explain  the  fact  that  the 
adhesions  are  never  so  pronounced  in  the  sulci  as  upon  the 
convexity  of  the  convolutions.  On  the  other  hand,  certain 
mechanical  processes  of  softening  after  death  explain,  in 
part,  the  fact  that  detachment  of  the  meninges  generally 
removes  the  cortex  in  definite  layers.  Previous  disease  of 
the  tissues,  however,  is  the  cause  of  the  more  rapid  soften- 
ing of  certain  layers  in  the  dead  body  or  the  firmer  adhe- 
sion of  other  layers.  The  chronic  interstitial  inflamma- 
tion sometimes  gives  rise  to  sclerosis  of  the  tissues ;  in 
these  rare  cases  the  brain  substance  is  hard  and  firm  on 
section. 

The  morbid  processes  in  the  nerve  cells  may  be  briefly 
summarized.  The  pyramidal  cells  of  the  middle  layers 
are  often  affected  most  distinctly,  and  hence  the  cortex 
often  tears  here  when  the  membranes  are  detached.  The 
ganglion  cells  in  general  are  at  first  swollen,  contain  large 
nuclei  which  almost  fill  the  cell,  and  also  a  very  distinct 
nucleolus.  In  time  they  shrivel,  lose  their  sharp  outlines, 
and  the  cell  processes  disappear.  Fatty  degeneration  and 
pigmentation,  calcification  and  the  formation  of  vacuolse  in 
the  cells  need  merely  be  mentioned  here. 

There  is  also  a  distinct  atrophy  of  medullated  nerve 
fibres,  and  quite  often  only  in  certain  parts  of  the  cortex 
and  medullary  tissue.  This  is  found,  in  approximately 
19 


290  HANDBOOK   OF   INSANITY. 

the  same  way,  only  in  closely  allied  forms  of  dementia, 
such  as  senile  and  epileptic  dementia,  and  in  connection 
with  the  other  findings  it  is  characteristic  of  general  pa- 
resis. 

The  changes  visible  to  the  naked  eye  appear  in  the 
following  manner.  Distinct  opacity  and  thickening  of 
the  meninges  extend  from  the  top  of  the  frontal  lobe  more 
or  less  uniformly  over  the  parietal  portions  to  the  occipital 
lobe,  where  a  sharply  defined  border  is  sometimes  observed. 
These  cases  seem  to  be  unattended  with  disturbances  of 
vision.  Even  when  the  latter  are  present,  the  extension 
of  the  disease  over  the  occipital  lobes  is  not  always  so 
distinct  that  we  may  assume  an  unquestioned  relation 
between  them.  The  thickening  of  the  meninges  is  a  proof 
of  disease  of  the  underlying  cortex.  In  dementia  para- 
lytica it  is  always  connected  with  encephalitic  processes, 
while  simple  leptomeningitis  may  develop  independently. 
Corresponding  to  the  distribution  of  the  microscopic 
changes,  the  thickening  and  adhesions  of  the  meninges 
are  most  pronounced  at  the  base  of  the  frontal  lobes,  the 
median  aspect  of  the  hemispheres  and  the  region  of  the 
island  of  Reil,  while  the  parietal  lobes  are  less  affected, 
especially  toward  the  base.  "When  the  speech  disturbances 
were  very  pronounced  an  unusual  degree  of  adhesion  of 
the  pia  to  the  speech  convolutions  on  the  left  side  has  been 
noted.  In  a  number  of  cases  the  adhesions  at  the  base  of 
the  frontal  lobes  were  associated  with  tabetic  symptoms. 

The  atrophy  of  the  convolutions  affects  mainly  the  fron- 
tal lobes,  the  superior  parietal  convolutions,  and  sometimes 
the  adjacent  part  of  the  temporal  lobe  and  insula,  occasion- 
ally the  occipital  lobe.  In  these  regions  the  convolutions 
are  narrowed  and  sometimes  exhibit  sharp  edges,  the  sulci 
gape ;  certain  parts  are  sunken.  A  section  of  the  convo- 
lutions shows  that  the  gray  cortex  is  very  narrow.  The 
entire  weight  of  the  brain,  and  especially  of  these  parts, 
is  greatly  lessened.  The  diminution,  on  the  average,  is 
100-200  gr.,  but  sometimes  the  weight  of  the  brain  falls 
below  1,000  gr.  (the  average  weight  of  the  brain  in  adult 


ANATOMICAL   CHANGES.  291 

males  is  1,350,  in  females  1,250).  The  changes  men- 
tioned are  usually  distributed  uniformly  over  both  hemi- 
spheres, but  no  slight  differences  in  this  regard  are  some- 
times found. 

The  ventricles  of  the  brain  may  be  greatly  dilated  so 
that  the  atrophy  of  the  brain  tissue  between  them  and  the 
surface  is  very  pronounced ;  atrophy  of  the  basal  ganglia 
is  exceptional.  Recently,  however,  atrophy  of  the  optic 
thalamus  has  been  observed  in  the  posterior  region,  espe- 
cially the  pulvinar,  and  has  been  supposed  to  be  related  to 
suddenly  developing  disorders  of  tactile  sensation,  speech, 
and  vision.  More  frequently  the  optic  tract  and  its  ap- 
pendages are  atrophied,  more  rarely  the  olfactory  bulb 
and  other  cerebral  nerves. 

Distinct  atrophy  of  the  fibres  has  been  found  occasion- 
ally in  the  central  tubular  gray  matter,  and  this  is  sig- 
nificant because  it  contains  numerous  fibres  which  connect 
it  with  the  optic  thalami.  Certain  observations  seem  to 
show  that  it  is  the  path  for  the  production  of  expressive 
movements,  and  that  the  association  of  the  thalamus  and 
central  tubular  gray  matter  may  perhaps  be  the  central 
point  for  mimic  innervation.  At  all  events,  there  appears 
to  be  no  doubt  that  in  dementia  paralytica  the  more  com- 
plicated disorders  of  movement  may  be  considerably  in- 
creased by  the  atrophy  of  fibres  in  the  central  tubular 
gray  matter. 

Greater  clinical  interest  attaches  to  hsematoma  of  the 
dura  mater,  although  it  is  not  very  constant  and  is  also 
found  in  other  psychoses,  injuries  to  the  skull,  other  dis- 
eases of  the  brain,  and  occasionally  in  constitutional  dis- 
eases, such  as  tuberculosis.  The  hsematoma  is  a  membrane 
on  the  inner  surface  of  the  dura  mater,  usually  in  the 
distribution  of  the  middle  meningeal  artery  (at  the  apex 
of  the  parietal  lobes),  but  sometimes  extending  to  all  the 
cerebral  fossae.  It  is  generally  a  loose  yellowish  deposit, 
infiltrated  with  hemorrhagic  extravasations,  and  can  be 
separated  from  the  dura.  Renewed  hemorrhages  may 
gradually  result  in  a  very  extensive  membrane,  which 


292  HANDBOOK   OF   INSANITY. 

may  produce  special  symptoms  as  the  result  of  com- 
pression of  the  brain  (especially  series  of  epileptiform 
attacks) . 

Changes  are  sometimes  found  in  the  nuclei  of  the  me- 
dulla oblongata,  for  example,  colloid  degeneration  of  the 
hypoglosssal  and  facial  nuclei. 

Apart  from  the  disease  of  the  posterior  columns  of  the 
spinal  cord  peculiar  to  tabes,  we  very  often  find  a  chronic 
myelitis  of  the  postero-lateral  columns,  especially  when  the 
dementia  runs  a  slow  course.  More  rarely  there  are  scat- 
tered myelitic  or  sclerotic  foci.  In  galloping  dementia  the 
spinal  cord  is  unchanged. 

The  diagnosis  of  progressive  paresis  with  delusions  of 
grandeur  is  usually  not  very  difficult  when  the  disease 
has  reached  its  height.  It  is  more  difficult  during  the 
prodromal  period.  Special  consideration  must  be  paid  to 
the  change  of  character,  the  loss  of  former  higher  interests, 
ethical  ideas  and  aesthetic  feelings,  and  the  impairment  of 
memory  and  judgment;  then  the  mild  vertiginous  attacks 
and  the  numerous  motor  disturbances  among  which  the 
more  prominent  are  myosis  and  the  speech  disorders ;  at- 
tention may  again  be  called  to  the  increase  of  the  latter  on 
reading  aloud  as  an  aid  in  diagnosis.  It  is  well  to  have 
the  patient  read  rapidly,  when  all  defects  often  become 
surprisingly  distinct. 

At  this  period  neurasthenics  present  many  of  these 
symptoms.  But  profound  change  of  character  and  ethi- 
cal and  intellectual  weakness  are  absent  in  neurasthenia. 
The  patient  also  observes  the  motor  symptoms  very  care- 
fully, while  the  paralytic  usually  does  not  notice  them. 
Tremor  of  the  tongue  and  associated  movements  of  the 
facial  muscles  in  speaking  are  seen  very  rarely  in  neuras- 
thenia. The  readiness  with  which  such  patients  are  ex- 
hausted is  shown  by  the  increase  of  the  speech  disorders 
after  exertion,  but  after  a  night's  rest  they  are  least  pro- 
nounced. In  dementia  paralytica  the  speech  disorder  is 
also  distinct  immediately  after  waking.  The  mental 
weakness  in  the  latter  is  also  shown  by  the  insufficient 


DIAGNOSIS.  293 

arrangement  of  speech  concepts,  so  that  there  is  much 
greater  hesitation  in  speaking. 

For  a  time  the  disease  may  sometimes  be  mistaken  for 
mania,  when  delusions  of  grandeur  and  a  condition  of  ex- 
citement are  well  developed.  But  mania  develops  with 
comparative  rapidity,  while  the  prodromes  of  paresis  often 
date  back  for  years.  Attention  should  also  be  directed  to 
the  monstrous,  unbounded  character  of  the  delusions  of 
grandeur.  Finally,  the  speech  disorders  and  paralytic 
seizures  possess  decisive  importance.  There  are,  however, 
cases  in  which  the  symptoms  of  complete  mania  last  for 
several  months  before  motor  disturbances  begin. 

If  a  depressed  mood  predominates  and  the  delusions 
have  negative  contents,  especially  when  they  are  associated 
with  feelings  of  derogation  concerning  the  patient's  own 
body,  the  condition  may  be  mistaken  for  melancholia.  If 
evidences  of  mental  weakness  are  found,  and  especially  if 
the  age  is  favorable  to  the  development  of  dementia  para- 
lytica, the  outbreak  of  this  disease  is  to  be  feared. 

At  certain  periods  paranoia  exhibits  certain  similarities 
to  dementia  paralytica,  but  they  disappear  on  closer  obser- 
vation. The  delusions  of  the  former  are  firmly  systema- 
tized, and  it  exhibits  no  motor  disorders.  There  is  also  a 
great  difference  in  the  two  diseases  with  regard  to  the 
mental  ability  and  judgment  .of  matters  which  are  not 
related,  to  the  contents  of  the  delusions.  For  example,  the 
paranoiac  almost  always  recognizes  insanity  in  others :  the 
paralytic  dement  hardly  ever  does  so. 

The  forms  of  dementia  which  are  associated  with  paral- 
yses (and  which  will  be  discussed  in  the  following  section) 
are  distinguished  by  the  greater  constancy  of  the  accom- 
panying hemiplegias  or  other  paralyses.  The  development 
and  course  of  the  disease  and  the  age  of  the  patient  also 
aid  in  diagnosis.  Mistakes  are  often  made,  however,  es- 
pecially when  diffuse  and  circumscribed  changes  in  the 
brain  are  associated  with  one  another. 

Without  a  knowledge  of  the  previous  history  it  is  often 
•difficult  to  distinguish  general  paresis  from  epileptic  in- 


294  HANDBOOK    OF   INSANITY. 

sanity,  because  the  latter  may  also  exhibit  weakness  of 
memory,  speech  disorders,  occasionally  even  delusions  of 
grandeur,  and  an  epileptiform  attack  may  occur  in  the 
same  manner  in  both  affections.  In  epileptics,  however, 
all  these  symptoms  usually  diminish  rapidly  as  the  inter- 
val after  the  attack  increases.  The  religious  character  of 
the  delusions,  the  reckless  violence  of  the  acts  of  the  epi- 
leptic, who  is  usually  in  a  dreamy  state,  are  further  means 
of  differentiation.  Apart  from  the  fits,  an  epileptic  dement 
may  resemble  a  paralytic  dement  very  closely,  but  this 
form  of  dementia  usually  develops  at  an  early  age,  and 
remains  in  statu  quo  for  many  years. 

The  treatment  of  the  disease  in  its  incipiency  is  of  chief 
importance  to  the  practitioner  because  the  fully  developed 
malady  offers  no  prospect  of  recovery. 

Inasmuch  as  mental  strain  of  every  kind  is  the  chief 
etiological  factor,  the  first  requisite  is  the  greatest  possible 
rest.  This  necessitates  the  removal  of  the  patient  from 
his  accustomed  surroundings.  He  is  thus  separated  from 
his  occupation  and  family,  and  at  the  same  time  from  a 
hundred  slight  influences  which  daily  irritated  him.  The 
new  surroundings  should  contain  no  new  irritants ;  hence 
a  prolonged  stay  in  the  country  with  a  stranger  is  advisa- 
ble. Travel  for  purposes  of  recreation  should  be  avoided. 
Bodily  and  mental  repose  must  be  secured  in  all  directions. 
If  morbid  sexual  excitement  is  manifested  in  a  married 
man,  the  removal  of  the  possibility  of  excesssive  inter- 
course will  exert  a  good  influence.  If  he  seeks  to  gratify 
his  desires  with  other  women,  this  very  fact  may  make  it 
necessary  to  transfer  him  to  an  asylum.  This  may  also 
be  necessary  at  the  start,  on  account  of  a  tendency  to  sui- 
cide, refusal  to  take  food,  extravagance  or  offences  against 
public  morals.  Otherwise  the  patient  should  not  be  re- 
moved to  an  asylum  at  too  early  a  period,  especially  if 
violent  affects  are  absent.  When  nursing  and  the  care  of 
the  patient  become  difficult,  he  may  be  removed  to  a  hos- 
pital. But  when  the  disease  exhibits  notable  remissions, 
which  may  even  render  the  resumption  of  work  possible,, 


TREATMENT.  295 

it  is  surely  in  the  interests  of  the  patient  to  keep  him  out 
of  an  asylum  as  long  as  possible.  If  the  conditions  favor 
treatment  outside  of  an  asylum  and  away  from  home,  at 
least  six  months  to  a  year  will  be  required  to  secure  any 
prospects  of  permanent  success. 

We  must  warn  against  excessive  cold-water  cures  and 
douches,  and  also  against  all  exhausting  methods  of  treat- 
ment, such  as  anti-syphilitic  treatment  with  mercurial 
inunctions.  In  some  cases  this  is  followed  by  rapid  loss 
of  power  and  the  development  of  violent  excitement.  In 
cerebral  syphilis  with  paralytic  symptoms  inunction  treat- 
ment offers  greater  chances  of  success.  But  if  the  paral- 
ysis has  developed  to  such  a  degree  that  atrophy  of  the 
brain  tissue  may  be  assumed,  we  must  protest  vigorously 
against  active  treatment  by  inunctions.  Hypodermic  in- 
jections of  mercury  seem  to  be  especially  dangerous  on 
account  of  the  frequent  formation  of  abscesses.  Even 
when  inunctions  are  employed  at  an  early  stage,  they 
should  only  be  continued  for  a  short  time;  if  improve- 
ment does  not  take  place  rapidly,  the  treatment  should  be 
discontinued. 

Potassium  iodide  is  a  less  dangerous  remedy  than  mer- 
cury, but  no  unquestioned  successes  have  been  obtained 
through  the  action  of  this  agent.  Inunctions  of  tartar- 
emetic  ointment  upon  the  shaven  scalp  have  been  recom- 
mended, but  the  results  are  more  than  doubtful,  and  this 
measure  should  not  be  employed  in  private  practice. 

Insomnia  requires  early  treatment.  The  remedy  which 
succeeds  most  frequently  is  chloral  hydrate,  in  combina- 
tion with  morphine.  Chloral  may  not  be  given  con- 
tinuously because  it  increases  the  weakness  of  the  vascu- 
lar system,  as  shown  by  local  cutaneous  affections  and 
rapidly  spreading  compression-gangrene.  In  many  cases 
sulfonal  is  a  good  substitute,  and  if  this  is  refused  injec- 
tions of  hyoscine  often  give  good  results. 

Anxious  excitement,  which  may  attain  the  highest 
grades,  is  best  combated  by  hypodermics  of  morphine. 
Milder  grades  are  relieved  by  prolonged  baths.     Violent 


296  HANDBOOK   OF   INSANITY. 

restlessness  generally  subsides  after  isolation,  which  i 
usually  be  of  short  duration. 

In  paralytic  attacks  of  long  duration  the  evacuation  of 
the  bladder  and  rectum  must  be  carefully  attended  to. 
The  increasing  imbecility  sometimes  necessitates  artificial 
feeding,  preferably  through  the  nose.  The  danger  of 
"  swallowing  the  wrong  way"  is  best  avoided  by  carefully 
feeding  the  patient. 

Careful  attention  to  cleanliness  by  frequent  lukewarm 
baths  seems  to  prevent  bed-sores ;  the  position  of  the  body 
must  also  be  changed  regularly.  The  greatest  difficulties 
in  nursing  arise  when  rigid  tension  of  the  muscles,  with 
feelings  of  fear,  has  developed.  Cleanliness  and  feeding 
then  demand  forcible  interference. 


D.  OTHER  FORMS  OF  DEMENTIA  WITH  PARALYSIS. 

Cerebral  Syphilis. 

The  relations  of  syphilis  to  dementia  paralytica  have 
already  been  considered.  "When  it  appeared  to  act  as  a 
casual  factor,  the  period  which  elapsed  between  its  ex- 
istence and  the  onset  of  the  dementia  was  usually  so  long 
that  it  appeared  to  act  rather  by  producing  general  weak- 
ness of  the  organism  than  by  specific  disease.  A  differ- 
ent condition  results  when  definite  anatomical  changes 
of  a  specific  character  are  associated  directly  with  clin- 
ical symptoms.  We  will  first  consider  diffuse  syphilitic 
affections. 

Post-mortem  examinations  have  shown  that  cerebral 
hemorrhages,  as  the  result  of  syphilitic  disease  of  the  ves- 
sels, may  occur  as  early  as  the  fourth  month  after  infec- 
tion, and  that  a  third  of  the  cases  of  syphilitic  disease  of 
the  nervous  system  occurs  within  the  first  year.  In  a  ma- 
jority of  cases,  however,  nervous  syphilis  does  not  begin 
until  years  after  infection.  The  localization  in  the  brain 
may  be  determined  by  cerebral  concussion  or  mental  over- 
work.    The  disease  is  first  manifested  in  the  small  arter- 


VESSEL   CHANGES.  297 

ies,  which  become  narrowed  and  are  finally  converted  into 
impermeable  bands.  Gummous  new  formations  on  the 
vessels  are  also  found. 

The  changes  in  the  vessels  produce  partial  or  complete 
interference  with  circulation  in  the  corresponding  parts  of 
the  brain,  with  or  without  softening.  This  explains  the 
fleeting  character  of  circumscribed  paralyses  due  to  the  nar- 
rowing of  small  arteries,  and  the  obstinacy  of  such  symp- 
toms as  hemiplegia  and  aphasia,  which  are  due  to  occlu- 
sion of  larger  vessels.  As  the  changes  in  the  vessels  are 
almost  always  associated  with  inflammation  of  the  dura 
mater  and  adhesion  of  the  meninges  to  the  convexity  of 
the  brain,  we  thus  find  anatomical  conditions  which  serve 
to  explain  the  similarities  as  well  as  the  differences  be- 
tween cerebral  syphilis  and  typical  dementia  paralytica. 
The  accompanying  symptoms  often  lead  to  the  diagnosis  of 
cerebral  syphilis.  A  characteristic  sign  is  the  extremely 
violent  headache  which  is  very  obstinate  and  is  especially 
severe  at  night.  Another  important  symptom  is  circum- 
scribed anaesthesia,  particularly  in  the  face,  associated 
with  paralysis  of  the  third  nerve.  Other  cerebral  nerves 
may  also  be  paralyzed,  but  the  changeability  of  the  symp- 
toms is  usually  a  striking  feature  so  long  as  larger  foci  of 
disease  are  wanting.  In  addition  there  is  a  combination 
of  symptoms  in  anatomically  distinct  tracts ;  for  example, 
left  hemiplegia  and  aphasia,  paresis  of  the  right  leg  and 
left  arm,  etc. — symptoms  which  cannot  be  referred  to  a 
single  origin.  These  conditions  develop  and  usually  dis- 
appear gradually.  Complete  loss  of  consciousness  is  not 
common,  but  peculiar  conditions,  like  intoxication,  are  ob- 
served, from  which  the  patients  can  only  be  roused  incom- 
pletely ;  at  times  they  give  surprisingly  rational  questions 
and  then  relapse  quickly  into  deep  sleep. 

The  mental  disorders  are  also  characterized  by  incom- 
pleteness of  the  symptoms  when  small  vessels  are  affected. 
The  location  of  the  disease  in  the  frontal  lobes  gives  rise 
to  symptoms  which  closely  resemble  those  of  paralytic  de- 
mentia.    Usually  this  is  the  pure  demented  form,  with- 


298  HANDBOOK   OF   INSANITY. 

out  increased  or  diminished  affects;  pronounced  delusions 
are  still  less  frequent,  although  delusions  of  grandeur  are 
occasionally  distinct.  A  striking  discrepancy  is  shown 
when  a  patient  who  is  apparently  profoundly  demented 
unexpectedly  manifests  the  delusions  of  grandeur,  as  the 
result  of  some  accidental  external  cause.  Even  in  the 
prodromal  period  there  is  a  confusing  variety  and  change- 
ability of  the  symptoms,  but  the  mental  weakness  appears 
at  a  very  early  period.  The  memory  and  mental  faculties 
in  general  fail  rapidly,  the  higher  feelings  become  blunted, 
and  great  irritability  and  capriciousness  set  in.  The  fa- 
cial expression  is  stupid.  Although  progressive  dementia 
predominates  the  scene,  violent  conditions  of  excitement 
occasionally  occur  and  furnish  a  transition  between  the 
vague  prodromata  and  the  more  distinct  dementia ;  violent 
conditions  of  fear,  with  terrifying  hallucinations,  are  also 
observed  at  times.  The  greatest  resemblance  to  dementia 
paralytica  often  follows  the  onset  of  paralytic  seizures 
and  speech  disturbances,  but  they  may  be  distinguished 
by  their  changeable  and  temporary  character. 

The  duration  is  also  extremely  variable;  sudden  im- 
provement and  relapse  occur,  or  even  unexpected  death 
during  a  paralytic  attack. 

Syphilitic  affections  usually  begin  at  an  earlier  age  than 
typical  paresis,  so  that  the  suspicion  of  underlying  syphilis 
becomes  less  when  a  doubtful  clinical  history  begins  in 
later  life.  As  a  matter  of  course,  the  diagnosis  of  syphilis 
is  greatly  aided  by  the  discovery  of  cicatrices,  thickenings 
of  the  bones,  buboes,  etc.  In  doubtful  cases  we  may 
adopt  experimental  treatment  with  potassium  iodide  and 
inunctions.  If  this  proves  beneficial,  the  treatment  may 
be  continued  more  boldly.  But  unless  some  distinct  benefit 
is  obtained  soon  after  the  first  inunctions,  we  must  be  very 
careful  in  the  protracted  administration  of  anti-syphilitic 
remedies.  The  anti-syphilitic,  as  well  as  other  treatment, 
depends  upon  general  principles  which  cannot  be  dis- 
cussed here. 


CEREBRAL   SCLEROSES.  299 


Diffuse  Cerebral  Sclerosis,  Gliosis,  etc. 

Certain  other  diffuse  diseases  of  the  brain  run  a  clinical 
course  which  is  attended  by  many  of  the  symptoms  of 
progressive  dementia  with  paralysis.  They  can  rarely  be 
recognized  during  life,  but  may  occasionally  be  suspected 
from  certain  signs.  In  diffuse  cerebral  sclerosis  there  is 
an  extensive  increase  of  connective  tissue  in  one  or  both 
hemispheres,  sometimes  confined  to  circumscribed  parts, 
but  distinguishable  from  insular  sclerosis  by  the  fact  that 
the  transition  into  non-affected  parts  is  gradual.  The 
brain  substance  is  firm  and  cut  with  difficulty.  Atrophy 
of  the  brain  appears  to  proceed  very  slowly.  Inflamma- 
tions of  the  meninges  are  also  found  often  in  combination 
with  sclerosis. 

As  the  encephalitis  which  gives  rise  to  sclerosis  is  very 
often  unilateral,  the  motor  and  sensory  disorders  likewise 
are  chiefly  unilateral.  Rhythmical  twitchings  in  certain 
parts  of  the  paralyzed  side  and  tremor  are  regarded  as 
characteristic.  This  is  an  important  fact  because  the.  ac- 
companying mental  disturbances  have  great  similarity  to 
simple  progressive  dementia ;  the  resemblance  is  increased 
still  more  when  speech  troubles  develop.  The  patients  are 
usually  men  between  the  ages  of  thirty  and  fifty  years ;  the 
disease  terminates  fatally  in  a  few  years. 

Another  diffuse  affection  of  the  brain,  known  as  gliosis,, 
is  confined  to  the  superficial  layers  of  the  cortex  in  which 
the  glia  undergoes  pronounced  proliferation.  This  process 
is  associated  with  the  formation  of  cavities  and  atrophj^ 
of  the  nervous  elements.  The  disease  begins  generally  in 
early  childhood  with  convulsions  and  mental  irritability ; 
later  it  may  assume  the  form  of  paralytic  dementia,  often 
associated  with  optic  atrophy  and  symptoms  of  tabes. 

The  cortex  may  also  be  affected  in  other  ways,  for  ex- 
ample, after  diseases  of  the  meninges,  so  that  numerous 
clinical  pictures  may  develop;  among  these  progressive 
dementia  is  noticeable.     It  is  impossible  to  give  a  general 


300  HANDBOOK   OF   INSANITY. 

description  of  all  these  forms,  which  vary  according  to  the 
predominant  affection  of  this  or  that  part  of  the  cortex. 

Focal  Diseases  of  the  Brain. 

When  violent  purulent  inflammations  of  the  brain 
which  lead  to  the  formation  of  abscesses  give  rise  to  psy- 
chical disorders,  the  latter  generally  occupy  the  back- 
ground. The  action  of  the  causal  agent  usually  is  fol- 
lowed rapidly  by  a  profound  impairment  of  consciousness 
which  prevents  the  prominence  of  individual  signs  of 
mental  disturbance.  As  soon  as  the  course  of  the  disease 
has  become  chronic,  certain  more  definite  signs  of  mental 
derangement  will  attract  attention,  and  if  the  previous 
history  is  imperfectly  known  the  condition  may  be  as- 
sumed to  be  purely  psychiatric.  This  is  also  true  of  brain 
tumors  and  of  the  sequelae  of  cerebral  hemorrhage,  em- 
bolism, and  thrombosis.  As  a  rule  the  psychical  phe- 
nomena depend  upon  the  extent  to  which  the  cortex  is  in- 
volved, but  decided  impairment  of  intelligence  may  also 
be  produced  when  the  lesion  is  situated  below  the  cortex. 
In  such  cases  it  is  very  probable  that  disease  of  the  vessels 
has  given  rise  to  the  focal  lesion  as  well  as  to  the  coinci- 
dent mental  disorder. 

We  cannot  enter  here  into  the  description  of  the  numer- 
ous symptoms  of  focal  lesions  of  the  brain,  especially  as 
they  possess  only  minor  importance  as  regards  a  knowledge 
of  the  accompanying  psychosis.  But  the  distinction  be- 
tween tumors  and  simple  softening  spots  may  here  be  in- 
dicated. In  the  former  we  usually  find  a  depressed  and 
tearful  mood,  the  patients  are  retiring  and  finally  become 
apathetic  and  imbecile.  In  addition  there  is  changeable- 
ness  of  mood;  the  intelligence  and  memory  are  usually 
impaired.  In  the  later  course  sombre,  tearful  affects  be- 
come more  frequent.  Complete  psychoses  are  rarer  and 
almost  always  '  exhibit  the  signs  of  progressive  dementia. 
Otherwise  the  symptoms  vary  according  to  the  location 
of  the  tumor.     Choked  disc  and  optic  neuritis  are  present 


FOCAL  LESIONS.  301 

in  almost  all  cases,  and  contractions  of  the  field  of  vision 
are  also  common.  The  greater  or  less  prominence  of  the 
psychical  symptoms  depends  in  a  measure  on  the  rapidity 
of  growth  of  the  neoplasm.  In  cerebral  hemorrhages 
aphasia  is  a  very  frequent  symptom,  and  in  consequence 
thereof  the  patient  often  appears  more  demented  than  he 
really  is.  After  the  aphasia  has  lasted  a  considerable 
time,  the  general  course  of  the  mental  processes  also  suf- 
fers deterioration.  The  patients  usually  have  a  very  irri- 
table, tearful,  but  changeable  mood. 

In  multiple  sclerosis,  progressive  dementia  and  sj)eech 
disorders  may  simulate  paralytic  dementia,  but  the  voli- 
tional tremor  and  nystagmus  permit  a  correct  diagnosis 
at  an  early  period.  The  signs  of  spinal  disease  also  appear 
more  distinctly  and  earlier  than  in  general  paresis.  Scle- 
rosis does  not  begin  after  the  age  of  forty  years. 

The  symptoms  of  syphilitic  lesions  when  due  to  the  oc- 
clusion of  large  vessels  also  fall  under  this  head. 

In  general,  focal  diseases  of  the  brain  rarely  come  under 
psychiatric  treatment  and  belong  rather  to  diseases  of  the 
brain  proper.  It  must  be  kept  in  mind  that  psychical  dis- 
eases are  diffuse  diseases  of  the  cerebral  cortex,  and  it  is 
only  by  assuming  an  influence  upon  the  cortex  in  general 
that  we  can  explain  the  occurrence  of  mental  disorders  in 
focal  lesions.  As  a  rule,  the  irritative  phenomena  in  such 
cases  are  temporary,  and  all  the  various  focal  diseases  end 
in  dementia. 

The  treatment  depends  on  the  symptoms  and  follows  the 
general  principles  already  laid  down  for  the  treatment  of 
psychical  disorders. 

E.    MENTAL   DISEASE   IN   EPILEPSY. 

We  now  turn  to  the  consideration  of  those  mental  dis- 
orders which  are  associated  with  general  diseases  of  the 
nervous  system.  The  general  neuroses,  of  which  the  most 
important  to  us  are  epilepsy,  hysteria,  and  neurasthenia, 
must  be  considered  from  two  standpoints,  according  as 


302  HANDBOOK   OF   INSANITY. 

they  affect  healthy  nervous  systems  or  develop  in  individ- 
uals whose  nervous  system  is  below  par  on  account  of 
hereditary  taint.  In  the  former  event  they  may  run  their 
course  without  affecting  the  mental  processes ;  in  the  latter 
some  mental  disturbance,  however  slight,  will  result. 

The  mental  disorders  which  occur  in  epilepsy  present 
great  differences.  While  some  individuals  suffer  from 
distinct  epileptic  attacks  and  in  the  intervals  exhibit  not 
the  slightest  mental  abnormality,  yet  as  a  rule  the  neuro- 
sis impairs  the  mental  life  to  a  greater  or  less  extent.  Al- 
though milder  conditions  of  irritability  and  mental  weak- 
ness are  not  very  striking,  they  are  apt  to  pass  into  severe 
mental  disorders.  This  is  true  of  about  a  third  of  all  epi- 
leptics. A  slight  change  of  character  is  usually  noticeable 
at  an  early  period ;  subsequently  low  impulses  become  prom- 
inent and  are  attended  by  general  weakening  of  the  in- 
telligence. There  is  also  an  entire  series  of  peculiar  con- 
ditions which  are  very  characteristic  of  the  epileptic  basis. 

The  most  important  feature  of  an  epileptic  attack  is  the 
disturbance  or  loss  of  consciousness,  while  convulsions 
may  be  entirely  absent.  In  addition  to  fully  developed 
attacks,  there  are  mild  vertiginous  conditions  in  which 
there  is  merely  a  brief  (a  few  seconds  to  half  a  minute) 
loss  of  consciousness,  associated  with  interruption  of  any 
occupation  which  has  been  begun  and  unattended  with 
spasms.  The  patient  suddenly  stops  in  the  midst  of  any 
occupation,  stares  vacantly  for  a  few  moments,  sighs 
deeply,  and  the  attack  is  past.  He  then  continues  his  in- 
terrupted occupation.  These  conditions  are  recognized 
most  easily  as  true  epilepsy  when  they  alternate  with  con- 
vulsive seizures.  There  are  also  numerous  transitions  from 
these  slight  attacks  to  the  more  severe  ones. 

There  are  a  number  of  psychical  disorders  which  may 
take  the  place  of  an  epileptic  attack,  such  as  so-called  epi- 
leptic dreamy  states,  true  psychical  equivalents,  and  epi- 
leptoid  conditions.  In  psychical  epileptic  attacks  there  is 
usually  complete  loss  of  memory  of  events  during  the  at- 
tack, and  the  mental  disorder  often  appears  almost  sud- 


EPILEPTIC   AURA.  303 

denly.  Often,  however,  we  find  an  aura,  as  in  simple  epi- 
lepsy, but  the  psychosis  proper  usually  appears  without  a 
prelude.  Gradually  a  peculiar  condition  of  mind  develops 
between  the  periodical  attacks,  and  must  be  distinguished 
from  the  aura  which  immediately  precedes  the  attack. 
Hence,  we  must  first  consider  those  mental  disorders  which 
develop  before,  during,  or  after  an  epileptic  attack,  and 
then  those  which  develop  during  the  intervals.  Later  we 
will  consider  the  true  epileptic  psychoses,  which  extend  be- 
yond the  period  of  an  attack. 

The  epileptic  aura  may  consist  of  various  mental 
changes,  lasting  a  few  minutes  or  hours.  For  several 
hours  before  an  attack  some  epileptics  become  depressed 
and  irritable ;  others  exhibit  great  slowness  of  comprehen- 
sion, weakness  of  memory,  and  apathy  toward  higher 
ethical  notions ;  still  others  exhibit  an  unusual  cheerful- 
ness, great  reliance  upon  their  own  powers,  and  this  in- 
creases perhaps  into  a  condition  of  great  restlessness  and 
loquacity. 

Intellectual  disorders  which  precede  the  attack  by  a  few 
minutes  belong  more  directly  to  the  attack  itself;  this  be- 
comes so  much  more  distinct  when  the  same  notion  or 
hallucination  constantly  returns  just  before  every  attack. 
Thus  the  patients  see  flames,  often  the  colors  red  and 
purple ;  they  hear  bells  ringing  or  a  distinct  voice ;  some- 
times they  notice  an  odor  or  stench.  These  phenomena 
are  usually  repeated  in  the  same  patient  in  exactly  the 
same  manner  with  every  fresh  attack. 

On  account  of  the  impairment  of  consciousness,  special 
mental  disorders  at  this  time  are  noticed  very  little.  But 
it  is  worthy  of  note  that  some  patients,  after  the  termina- 
tion of  a  spasmodic  seizure,  retain  a  certain  summary 
memory  of  the  notions  which  appeared  during  the  attack 
in  their  clouded  consciousness.  They  then  describe  the 
condition  as  a  disagreeable  dream,  or  there  may  be  violent 
qualms  of  conscience  or  thoughts  of  indescribable  misfor- 
tune, although  they  are  unable  to  base  these  feelings  on 
reality. 


304  HANDBOOK   OF   INSANITY. 

The  mental  disorders  after  the  epileptic  attack  are  more 
important.  The  patients  are  then  more  or  less  imbecile 
for  a  few  minutes  to  a  few  hours.  It  is  difficult  for  them 
to  collect  their  thoughts,  to  account  for  the  persons  and 
things  around  them.  Some  remain  in  this  condition  for 
hours,  and  are  very  sad  and  depressed,  while  others  are 
tormented  by  an  indefinable  fear. 

Other  mental  disturbances  may  also  appear  immediately 
after  an  epileptic  attack.  After  a  few  moments  of  rigidity 
there  may  rapidly  develop  a  condition  of  great  violence 
and  blind  rage,  probably  accompanied  in  many  cases  by 
frightful  hallucinations,  and  manifested  by  the  most  reck- 
less violence  and  tendency  to  destruction.  The  patients 
do  not  retain  the  slightest  memory  of  this  condition.  More 
harmless  are  those  cases  in  which  the  patients  merely  walk 
about  restlessly  for  a  little  while,  but  there  are  gradual 
transitions  between  the  temporary  psychical  disorders 
which  follow  the  epileptic  attack  immediately  and  the 
long-continued  psychical  disorders  in  which  the  epileptic 
seizure  appears  to  be  of  minor  importance,  and  the  mental 
disorder  becomes  an  equivalent  for  it. 

We  must  first  devote  a  little  attention  to  the  ordinary 
mental  condition  of  epileptics  in  the  intervals  between  the 
different  spasmodic  seizures.  As  we  have  already  stated, 
there  are  some  epileptics  in  whom  not  the  slightest  trace 
of  mental  disorder  can  be  detected  in  these  intervals. 
In  the  majority  of  cases,  however,  peculiar  changes  can 
be  more  or  less  distinctly  recognized.  The  predominant 
characteristic  of  the  epileptic  is  his  irritability.  The  pa- 
tients are  usually  distrustful,  easily  angered,  and  become 
violent  on  very  slight  provocation  or  none  at  all.  They 
are  obstinate  and  constantly  moody.  The  irritable  mood 
becomes  especially  striking  on  account  of  the  frequent 
alternation  with  a  mood  of  entirely  different  character,  in 
which  the  patient  is  timid  and  reticent,  obeys  all  injunc- 
tions implicitly,  or  even  exhibits  complete  submissiveness, 
sometimes  tinged  with  tenderness  and  politeness.  At 
times   there    is   an   abnormal,    causeless    mirth.      These 


THE    EPILEPTIC    CHARACTER.  305 

symptoms  may  undergo  numerous  changes,  which  cannot 
be  attributed  to  external  causes.  Sometimes  they  per- 
form their  duties  diligently  and  carefully,  but  there  are 
times  in  which  this  becomes  impossible.  A  tendency  to 
lie  is  very  often  observed,  and  this  may  be  associated  with 
envy  and  jealousy.  Epileptics  are  often  intriguers  and 
indescribably  ingenious  in  lying,  but  at  the  same  time 
coarse  and  lacking  in  consideration  when  their  faults  are 
brought  home  to  them.  These  symptoms  are  always 
periodical,  so  that  we  are  surprised  occasionally  by  evi- 
dences of  good-humor  and  amiability. 

We  may  also  find,  in  the  interparoxysmal  periods,  a 
pseudo-religious  character,  in  which  a  great  deal  of  time 
is  devoted  to  reading  the  Bible.  This  characteristic  is  so 
much  more  disagreeable  because  it  is  almost  always  asso- 
ciated with  a  disappearance  of  ethical  feelings  in  actions 
toward  others. 

We  now  turn  to  the  consideration  of  epileptic  insanity 
proper.  Its  characteristics  are  the  periodical  paroxysmal 
recurrence  of  very  brief  and  violent  symptoms,  which  are 
either  forgotten  entirely  or  merely  remembered  summarily. 

Their  relationship  to  the  milder  psychical  changes  of 
an  epileptic  vertiginous  attack  is  shown  most  distinctly 
in  the  brief  dream  conditions,  whose  description  remind 
us  in  many  respects  of  the  losses  of  consciousness  already 
described.  The  condition  lasts  several  hours  or  days, 
consists  chiefly  of  great  confusion,  but  often  of  great  fear, 
and  is  often  accompanied  by  impulsive  acts.  The  prodro- 
mata  are  a  morose  manner  or  hopelessness,  increased  by  a 
vague  consciousness  of  what  is  impending,  if  the  pa- 
tient has  already  had  repeated  attacks.  He  begins  to 
wander  about  and  is  the  victim  of  an  indefinable  fear; 
attempts  at  explanation  sometimes  crop  out,  and  the  pa- 
tient regards  himself  as  the  victim  of  a  conspiracy.  Im-; 
pulsively  he  resists  and  seeks  revenge ;  suicide  and  homi- 
cide may  then  occur,  and,  particularly  in  young  people, 
incendiarism.  The  special  characteristics  of  these  acts 
are  their  violence  and  suddenness.  In  this  condition  the 
20 


30 G  HANDBOOK   OF   INSANITY. 

patients  attack  one  person  after  another,  and,  not  satisfied 
with  killing  the  supposed  enemy,  again  inflict  numerous 
wounds  upon  him  or  destroy  objects  in  a  blind  rage. 

These  attacks  are  often,  although  not  always,  accom- 
panied by  hallucinations.  They  possess  a  frightful  char- 
acter and  thus  intensify  the  affect.  Shining  objects,  fire, 
bloody  phantoms,  terrible  dangers,  ghosts,  more  rarely 
distinct  individuals,  such  as  a  black  man  or  the  devil, 
throng  upon  them.  Sometimes  they  surround  the  patient 
on  all  sides.  Auditory  hallucinations  are  rarer,  olfactory 
hallucinations  (stench)  somewhat  more  common. 

After  an  act  of  violence  has  been  done,  the  external  ex- 
citement may  rapidly  subside,  but  the  dreamy  condition 
generally  continues  for  some  time,  even  after  the  fear  has 
disappeared.  The  memory  of  what  has  occurred  may  be 
tolerably  clear  during  the  attack,  but  then  disappears  rap- 
idly, either  completely  or  only  partially,  so  that  the  patient 
is  able  to  remember  certain  events.  This  fact  should  lead 
us  to  exercise  great  caution  in  judicial  cases,  because  the 
suspicion  of  intentional  deceit  naturally  arises  if  a  confes- 
sion which  was  made  soon  after  the  act  is  afterward  dis- 
puted by  the  individual.  As  a  general  thing,  however, 
there  is  complete  loss  of  memory  during  the  entire  dura- 
tion of  the  attack. 

A  different  history  is  presented  by  the  "  dream  condi- 
tions" without  fear.  Here  the  contents  of  consciousness 
are  usually  of  a  religious  nature.  The  patient  sees  the 
heavens  open,  and  is  himself  an  angel,  God  or  Saviour. 
Or  he  plays  the  part  of  a  contrite,  finally  pardoned  sinner. 
Calling  the  name  of  God  is  almost  a  special  characteristic ; 
commands  received  from  God  impel  to  sudden  acts.  An- 
other notable  feature  is  the  frequency  with  which  acts  of 
sexual  violence  are  committed  during  this  condition.  The 
condition  generally  develops  very  rapidly,  but  the  disor- 
der of  consciousness  is  lost  very  gradually.  The  uni- 
formity of  the  individual  attacks  is  very  characteristic. 
This  is  also  true  of  another  series  of  epileptic  "dream 
conditions,"  in  which  the  contents  of  consciousness  revolve 


DREAM   STATES.  307 

around  romantic  events,  which  are  usually  invented,  but 
are  taken  seriously.  In  other  cases  the  patient  passes 
through  the  strangest  adventures  during  his  "  dream  con- 
dition." He  makes  long  journeys  and  finally  turns  up  in  a 
foreign  land  without  knowing  how  he  reached  there.  Such 
a  state  is  closely  allied  to  somnambulism,  and  in  some 
cases  the  latter  undoubtedly  belongs  to  the  group  of 
epileptic  "dream  states."  This  can  only  be  inferred, 
however,  when  the  patient  exhibits  other  signs,  such  as 
nocturnal  epileptic  attacks  with  enuresis,  biting  of  the 
tongue,  etc. 

The  epileptic  mental  disorders  hitherto  described  either 
accompanied  epileptic  spasmodic  seizures  or  took  their 
place,  and  were  of  brief  duration  (a  few  hours  or  days). 
Some  cases,  however,  furnish  a  transition  to  chronic  forms 
of  mental  disease.  Although  the  convulsions  here  play  a 
minor  part  in  the  clinical  history  and  may  even  be  entirely 
absent,  the  course  of  the  disease  has  the  symptoms  char- 
acteristic of  epileptic  insanity,  so  that  the  attacks  are  called 
prse-epileptic  and  post-epiletic,  or  are  regarded  as  psychical 
equivalents.  In  addition  to  their  greater  duration  (weeks 
and  months) ,  these  conditions  exhibit  less  impairment  of 
consciousness,  so  that  it  is  preferably  termed  dulness.  As 
these  conditions  do  not  differ  essentially  from  the  brief 
mental  disorders  on  an  epileptic  basis  which  have  already 
been  described,  we  will  merely  call  attention  to  a  few 
points  that  distinguish  them  from  other  simple  psychoses. 
Although  consciousness  is  not  abolished,  its  disturbance 
is  more  profound  than  in  ordinary  psychoses ;  its  onset  is 
more  rapid,  almost  sudden,  and  it  subsides  usually  after 
a  "  dream  state. "  The  loss  of  memory  of  the  attack  and 
of  everything  connected  with  it  is  often  complete.  The 
senseless  recklessness  of  the  patient's  acts  and  the  reli- 
gious tinge  of  the  contents  of  consciousness  are  further 
distinguishing  marks.  The  periodical  recurrence  of  sim- 
ilar attacks  is  significant,  and  if  they  alternate  with  con- 
vulsive seizures  every  doubt  is  removed.  Nocturnal  con- 
vulsions may  be  recognized  by   their  sequelae,   such   as 


308  HANDBOOK   OF   INSANITY. 

headache  and  exhaustion,  enuresis,  bites  in  the  tongue, 
extravasations  of  blood  into  the  conjunctiva  and  face, 
and  finally  the  peculiar  change  in  the  character  of  epilep- 
tics during  the  interparoxysmal  periods.  Difficult,  stutter- 
ing speech  may  also  persist,  as  a  sequel,  for  some  time. 
It  is  also  well  to  know  that  the  psychical  epileptic  equiva- 
lents are  usually  separated  more  widely  in  point  of  time 
than  ordinary  spasmodic  seizures. 

Finally,  one  form  of  mental  disorder  develops  after  a 
series  of  simple  epileptic  attacks  or  after  the  frequent  rep- 
etition of  single  attacks.  This  is  usually  known  as  epi- 
leptic degeneration.  It  is  manifested  chiefly  by  the  loss 
of  intelligence,  which  increases  progressively.  As  in  all 
psychoses  which  progress  to  dementia,  the  loss  of  the 
higher  mental  feelings  appears  earliest  and  most  distinctly. 
Hence,  we  here  find  cruel  acts  of  violence  which  are  un- 
opposed by  any  ideas  of  morality,  so  that  there  is  no 
question  of  subsequent  remorse.  The  intellectual  decay 
continues,  and  is  always  most  pronounced  immediately 
after  the  attacks,  so  that  perceptions  then  result  only  after 
stronger  stimuli.  For  a  long  time  there  is  great  irrita- 
bility, so  that  the  patient  becomes  violently  angry  on  slight 
provocation.  In  comparatively  few  cases,  however,  do 
we  find  the  highest  grades  of  apathetic  dementia  in  which 
the  patients  are  helpless  and  filthy.  It  must  be  regarded 
as  a  peculiarity  of  demented  epileptics  that  they  long 
(sometimes  always)  retain  the  sense  for  externals,  such  as 
cleanliness  of  clothing.  The  earlier  the  primary  epilepsy 
began  the  more  pronounced  does  the  dementia  become. 
Bodily  decay  and  paralyses  then  set  in,  together  with  dis- 
orders of  speech. 

The  term  status  epilepticus  is  applied  to  a  condition 
which  develops  when  the  patients,  as  the  result  of  the 
rapidly  succeeding  attacks,  no  longer  return  to  conscious- 
ness and  lie  as  if  in  coma.  Death  may  occur  in  this  con- 
dition. There  is  usually  a  rise  of  temperature  to  41°  or 
42°  C,  which  is  not  due  to  the  increased  muscular  action 
during  the  convulsions.     The  exhaustion  is  extreme  and 


STATUS   EPILEPTICUS.  309 

is  rapidly  increased  by  the  fact  that  the  patients  cannot 
be  nourished.  The  number  of  attacks  may  amount  to 
hundreds,  and  may  last  from  a  couple  of  weeks  to  a  month, 
with  brief  interruptions. 

Concerning  the  anatomical  basis  of  epilepsj^  and  its 
associated  mental  disorders  we  really  know  nothing  posi- 
tive. The  most  frequent  cause  is  heredity,  then  follow 
alcoholic  excesses,  drunkenness  of  the  parents,  and  con- 
ception while  drunk.  Next  come  the  cerebral  diseases  of 
early  childhood.  Another  important  cause  is  concussion 
of  the  brain  after  injuries  to  the  skull  and  the  allied  form 
of  psychical  trauma,  viz.,  fright. 

The  following  data  may  be  considered  in  regard  to  prog- 
nosis. Intelligence  is  more  apt  to  suffer  in  those  forms  of 
epilepsy  which  are  characterized  by  frequent  brief  loss 
of  consciousness  and  vertiginous  attacks  than  after  severe 
convulsive  seizures.  This  fact  appears  to  show  that  the 
mental  disorder  is  not  merely  a  sequel  of  the  attacks,  but 
that  both  are  different  manifestations  of  the  same  primary 
process.  The  chances  that  the  mental  powers  will  remain 
intact  are  also  so  much  greater,  the  rarer  the  attacks, 
whatever  their  character.  As  a  rule,  the  single  attacks 
recover,  but  in  general  the  mental  disorders  of  epilepsy 
must  be  regarded  as  a  very  unfavorable  form  of  disease. 

The  diagnosis  is  easy  in  pronounced  cases,  but  it  is 
sometimes  very  difficult  and  can  only  be  made  after  pro- 
longed observation  which  discloses  the  periodical  course. 
Many  cases  of  epileptic  insanity  have  probably  been  de- 
scribed as  transitory  mania,  and  this  mistake  is  avoided 
with  difficulty.  Such  cases  usually  last  only  a  few  hours 
to  one  day,  and  run  their  course  as  a  violent  attack  of  rage 
with  impulsive  acts  of  violence.  As  a  rule,  they  begin 
suddenly,  without  real  prodromata,  and  rapidly  attain 
their  maximum ;  they  are  accompanied  by  vivid  halluci- 
nations. After  the  excitement  the  patient  falls  into  a  deep 
sleep,  from  which  he  awakes  with  a  dull  head  and  a  feeling 
of  great  exhaustion  and  without  a  clear  memory  of  the 
things  that  have  happened.     Here  the  signs  of   an  epi- 


310  HANDBOOK    OF    INSANITY. 

leptic  basis  are  the  sudden  beginning,  the  profound  dis- 
turbance of  consciousness  with  subsequent  loss  of  memory, 
the  impulsive  violence  of  the  acts,  and  the  tolerably  sud- 
den cessation  of  the  symptoms. 

It  is  important  to  remember  that  psychoses  other  than 
those  described  may  also  be  associated  with  epilepsy.  If 
the  association  is  accidental,  such  psychoses  cannot  be 
called  epileptic.  Id  some  cases  secondary  dements  be- 
come epileptic  at  a  later  period,  so  that  it  may  be  assumed 
that  the  cortical  disease  has  extended  to  motor  regions. 
The  status  epilepticus  may  be  mistaken  for  eclampsia  and 
ursemia,  but  the  previous  history  and  the  examination  of  the 
urine  will  prevent  mistakes.  Certain  difficulties  may  also 
be  produced  by  a  condition  of  rigid  mutism,  which  has 
much  resemblance  to  profound  melancholia.  It  is  only 
after  this  has  run  its  course  that  we  find  a  distinguishing 
feature  in  the  defect  of  memory.  Conditions  of  stupor, 
alternating  with  verbigeration  and  mutism,  which  prob- 
ably have  an  epileptic  basis,  have  also  been  observed. 
But  these  clinical  conditions  are  interpreted  by  others  in 
a  different  way,  for  example,  as  katatonia,  and  their 
position  in  our  nosological  system  cannot  be  decided 
here. 

The  treatment  of  the  mental  disorders  of  epilepsy  is  the 
same  as  that  of  epilepsy  itself.  Potassium  bromide  en- 
joys great  repute  not  alone  in  preventing  convulsions  and 
excitement,  but  also  in  maintaining  the  mental  powers. 
The  effective  dose  varies  greatly  in  different  cases.  We 
generally  begin  with  2.0-6.0  daily  and  then  increase,  as 
required,  to  8.0-10.0;  the  remedy  is  continued  for  a  few 
weeks,  and  the  dose  is  then  diminished  or  discontinued. 
But  if  good  results  are  obtained,  a  dose  of  4.0  daily  may 
be  continued  unchanged  for  years.  In  asylums  we  are 
apt  to  be  mistaken  in  this  regard,  because  the  change  to 
new  and  well-regulated  surroundings  and  the  improved 
nutrition  may  have  been  more  efficient  .than  the  drug. 
Hence  it  is  preferable  to  delay  the  administration  of  the 
drug  unless  it  is  indicated  at  once  by  imperative  symp- 


HYSTERIA.  311 

toms.     After  an  attack  it  is  also  well  to  let  the  patient 
sleep  as  long  as  he  will  or  to  secure  sleep  by  drugs. 

When  potassium  bromide  is  useless,  atropine  or  curare 
may  be  employed,  although  good  results  are  rare.  Injec- 
tions of  morphine  may  relieve  the  severe  symptoms  in  the 
status  epilepticus;  chloral  enemata  are  also  recommended. 
It  must  be  kept  in  mind  that  patients  suffering  from  epi- 
leptic insanity  are  dangerous  to  others,  so  that  they  can- 
not be  removed  too  quickly  to  an  asylum.  Even  if  the 
progressive  dementia  is  only  slight,  sudden  acts  of  vio- 
lence may  make  the  patient  dangerous  to  himself  and 
others. 

F.    INSANITY   AND   HYSTERIA. 

The  answer  to  the  question  whether  hysteria  is  always 
a  mental  disorder  depends  upon  our  conception  of  mental 
disorder  in  general.  There  is  no  doubt  that  even  the 
mildest  forms  of  hysteria  are  often  attended  with  a  pecu- 
liar change  of  character,  which  we  find  again  in  all  forms 
and  degrees,  but  true  hysterical  insanity  is  a  different  affec- 
tion and  runs  its  course  under  definite  peculiar  symptoms. 

As  a  rule,  hysteria  is  a  congenital  and  inherited  consti- 
tutional neurosis,  so  that  the  mental  functions  exhibit 
many  evidences  of  being  below  par.  Hysteria  in  the 
male  is  so  rare  that  we  will  refer  only  to  the  affection  in 
the  female  sex.  The  disease  often  begins  in  childhood, 
but  most  frequently  at  the  period  of  puberty.  Although 
sexual  life  has  great  influence  on  the  disease,  still,  not 
more  than  half  the  patients  exhibit  any  irritative  condi- 
tions of  the  genitalia,  and  it  is  even  doubtful  whether 
these  are  cause  or  effect.  Furthermore,  even  the  slightest 
indications  of  sexual  excitement  are  often  absent  in  chronic 
uterine  disease  of  hysterical  patients. 

The  mental  symptoms  may  be  divided  into  three  groups : 
those  which  show  a  special  change  of  character;  those 
which  accompany  or  are  substituted  for  an  hysterical 
seizure ;  finally,  those  which  belong  to  hysterical  insanity 
proper. 


312  HANDBOOK    OP   INSANITY. 

From  early  childhood  the  majority  of  future  hysterical 
patients  exhibit  an  unstable  mental  equilibrium.  They 
are  very  impressionable,  laugh  or  cry  on  the  slightest 
provocation.  They  are  quick,  have  talent  for  study,  and 
a  natural  tendency  to  imitate,  a  certain  talent  for  acting. 
At  the  same  time  they  are  deceitful,  fond  of  command, 
excitable,  sometimes  very  depressed.  They  get  excited 
over  trifles  and  remain  unaffected  by  events  which  should 
touch  them  more  deeply.  They  often  suffer  from  numer- 
ous nervous  affections,  such  as  headache,  abdominal  pains, 
palpitation,  nightmare,  feeling  of  pressure  in  the  throat, 
occasionally  distinct  spasmodic  seizures.  To  these  real 
complaints  they  often  add  imaginary  ones  in  order  to 
make  themselves  interesting.  Religious  tendencies  at  a 
very  early  age  with  conditions  of  ecstasy  are  signs  of  an 
hysterical  basis. 

In  adult  hysterical  patients  these  predispositions  de- 
velop with  varying  intensity.  A  changeableness  of  char- 
acter is  first  observed.  Without  any  internal  reason  they 
pass  from  cheerfulness  and  amiable  traits  to  moroseness, 
sensitiveness,  and  violence,  and  become  unjust  and  ma- 
licious. They  exaggerate  everything,  are  capricious  in 
their  feelings,  in  the  noblest  emotions  as  well  as  the  low- 
est impulses.  They  are  found  at  the  head  of  charitable 
associations,  and  redouble  their  energies  in  solacing  the 
down-trodden  and  in  uplifting  those  who  have  lost  hope. 
On  the  other  hand,  they  are  capable  of  the  greatest  moral 
transgressions,  and  finally  are  not  abashed  by  crime.  They 
are  spirits  of  opposition  and  contradiction.  To-day  they 
maintain  the  opposite  of  what  they  asserted  yesterday. 

But  despite  this  capriciousness  they  exhibit  remarkable 
persistence  under  certain  circumstances— complete  mutism 
on  account  of  the  fear  that  speaking  is  injurious ;  fasting 
for  weeks  in  order  to  avoid  gastric  disease ;  lying  in  bed 
for  years  in  the  firm  conviction  that  walking  is  impossible. 
But  such  obstinate  persistence  is  due  not  to  strength  but  to 
weakness  of  will. 

The  capriciousness  of  character  is,  however,  the  most 


HYSTEEICAL   SEIZURES.  313 

marked  feature.  An  hysterical  patient  who  has  been 
married  only  a  few  weeks  complains  that  she  is  mis- 
understood, that  she  has  not  found  the  one  whom  she 
could  make  happy  with  the  exuberance  of  her  love.  She 
makes  things  as  unpleasant  for  her  husband  as  possible, 
and  later  manifests  this  antipathy  even  to  her  children. 
Lying  is  a  constant  feature,  and,  in  a  measure,  is  the  sign 
manual  of  the  hysterical  character.  The  slyness  and  per- 
sistence with  which  useless  lies  are  told  are  sometimes 
astonishing.  Sometimes  they  consist  of  false  accusations 
and  slanders.  Hysterical  patients  have  wounded  them- 
selves with  knives  and  torn  their  own  clothes  in  order  to 
prove  an  accusation  of  rape.  Or  they  slander  others 
through  the  medium  of  letters  which  they  write  to  them- 
selves. The  chief  cause  of  such  acts  is  the  desire  to  ap- 
pear interesting. 

Even  the  tendency  to  sexual  excesses  which  is  often 
manifested  is  due  to  the  desire  to  make  themselves  prom- 
inent. In  some  cases,  however,  there  is  really  increased 
sexual  excitement.  The  patients  may  then  retain  the 
urine  in  order  to  secure  daily  catheterization,  or  feign 
disease  of  the  uterus  in  order  to  have  a  speculum  intro- 
duced. 

Every  hysterical  patient  may  pass  from  the  mildest  to 
the  most  severe  of  these  mental  disorders  and  finally  pass 
into  a  pronounced  psychosis.  The  main  elements  remain 
the  increased  excitability  and  diminished  will  power,  which 
is  increased  only  for  certain  perverse  purposes.  The  pa- 
tients follow  the  impulse  of  the  moment  and  are  incapable 
of  controlling  their  antipathies  against  individuals  and 
certain  impressions,  such  as  smells  and  sounds. 

The  intelligence  and  memory  are  not  much  affected. 
This  very  fact  makes  them  able  to  carry  out  their  designs, 
and  they  may  thus  become  veritable  nuisances  to  those 
around  them  and  to  the  physician. 

In  order  to  understand  the  relations  of  hysteria  to  epi- 
lepsy we  must  first  describe  hysterical  convulsions.  An 
hysterical  seizure  includes  numerous  other  physical  symp- 


314  HANDBOOK    OP   INSANITY. 

toms  besides  the  convulsions,  but  they  will  only  be  consid- 
ered with  regard  to  their  psychical  basis. 

The  sensory  and  motor  disorders  of  hysteria  have  no 
anatomically  conceivable  basis,  but  are  arranged  in  the 
sense  of  physiological  activity  and  at  the  same  time  show 
the  signs  of  psychical  origin. 

The  prodromata  of  a  spasmodic  seizure  are  usually 
so  distressing  to  the  patients  that  they  yearn  for  the  re- 
lieving action  of  the  spasms.  Great  restlessness  and  irri- 
tability distress  them,  and  the  attacks  are  also  preceded 
by  incessant  yawning  and  sighing.  The  symptoms  of  an 
aura  are,  however,  so  manifold  that  they  are  incapable  of 
coherent  description.  One  feature  is  common  to  most  of 
them,  viz.,  the  anxious  hoping  for  the  spasmodic  attack, 
while  the  epileptic  fears  the  seizure.  When  the  convul- 
sions begin  the  loss  of  consciousness  is  not  as  sudden  as 
in  epilepsy,  so  that  the  patients  do  not  injure  themselves 
in  falling.  At  the  onset  all  the  movements  are  still  ar- 
rayed in  a  regular  physiological  manner  and  stand  under 
psychical  guidance.  In  the  severest  cases  complete  loss 
of  consciousness  then  follows.  In  the  milder  cases  the 
patients  can  see  and  hear  everything  going  on  around 
them.  The  spasmodic  movements  are  very  extensive  and 
irregular  in  their  sequence. 

The  details  of  hysterical  seizures  cannot  be  entered  into 
here.  It  is  characteristic  of  many  cases  that  they  can  be 
interrupted  at  any  time  by  pressure  on  the  ovarian  region. 
This  effect  usually  lasts  only  during  the  continuance  of 
the  pressure.  The  single  attacks  generally  run  their 
course  in  about  a  quarter  of  an  hour,  but  they  may  be  re- 
peated and  even  amount  to  hundreds  (status  hystericus) . 

Contractures  due  to  tonic  spasms  are  subordinate  to  the 
psychical  processes  of  attention  and  volition ;  while  they 
are  frequent  in  hysteria,  they  do  not  occur  in  epilepsy. 
The  paralyses  of  hysteria  associated  with  sensory  disorders 
also  show  the  extreme  facility  with  which  psychical  stim- 
uli change  the  symptoms  of  the  disease.  Catalepsy,  with 
waxen  flexibility,  may  also  appear  in  hysteria  under  the 


DREAM    STATES.  315 

influence  of  the  psychical  excitability  and  coincident  dim- 
inution of  will  power.  The  psychical  influence  is  usu- 
ally recognizable  even  in  the  disorders  of  the  circulation 
and  the  secretory  organs.  Unlike  epilepsy,  the  persistence 
of  hysterical  seizures  for  years  produces  no  notable  dis- 
order of  intelligence. 

Although  we  are  not  in  the  habit  of  speaking  of  hyster- 
ical equivalents  or  post-hysterical  conditions,  it  cannot  be 
denied  that  similar  conditions  are  found  in  certain  "  dream 
states"  which  follow  or  replace  an  hysterical  attack. 
These  states  are  longer  or  shorter  attacks  of  impairment 
of  consciousness.  In  the  simplest  form  this  disorder  of  con- 
sciousness extends  beyond  the  spasmodic  stage  for  a  longer 
or  shorter  period.  The  patients  lie  with  relaxed  limbs, 
quiet  respiration  and  slow  pulse,  the  eyes  rolled  upward 
and  to  the  side.  In  exceptional  cases  this  condition  may 
last  days,  even  weeks. 

The  dream  states,  which  belong  to  the  domain  of  som- 
nambulism, must  be  regarded  as  equivalents  or  protracted 
hysterical  seizures.  The  patients  are  roused  with  com- 
parative difficulty  from  this  condition. 

The  dream  states  may  acquire  a  different  complexion 
from  the  addition  of  vivid  hallucinations ;  they  are  com- 
bined with  conditions  of  ecstasy  in  which  rigidity  of  the 
muscles  is  also  observed.  Hallucinations  of  sight  are  espe- 
cially important  and  are  often  of  a  terrifying  nature. 
The  patients  see  dark  shadows,  flames,  animals,  such  as 
rats  and  snakes,  also  larger  animals,  which  assume  fantas- 
tic shapes.  Naked  men,  corpses,  funerals,  murders,  are 
also  seen.  The  anxious  restlessness  may  be  increased  still 
further  by  threatening  voices  and  sounds  and  disagree- 
able odors. 

Still  more  frequent  are  ecstatic  conditions,  with  feelings 
of  delight  and  heavenly  phantasms,  and  this  is  shown  in 
the  patient's  appearance.  She  is  transferred  to  an  imag- 
inary world,  and  the  contents  of  consciousness  are  often 
chiefly  religious.  In  the  posture  of  prayer  or  ecstasy, 
with  the  eyes  turned  toward  heaven,  the  facial  expression 


316  HANDBOOK   OF   INSANITY. 

shows  complete  abandonment  to  bliss.  The  rigid  posture 
may  then  pass  into  that  of  crucifixion  or  it  imitates  other 
scenes  in  the  life  of  Christ  or  the  martyrs.  Praying,  the 
singing  of  psalms,  and  loud  prophecies  sometimes  break 
the  silence  for  a  time.  Later  the  patients  state  that  they 
felt  happy  in  paradise,  in  the  presence  of  God  and  the 
angels,  etc.  During  the  period  of  ecstasy  there  is  often 
insensibility  to  external  stimuli,  the  pulse  may  be  acceler- 
ated, the  respirations  slow,  the  pupils  wide. 

Sometimes  the  contents  of  consciousness  refer  to  some 
actual  previous  experience;  for  example,  an  attempted 
rape.  This  event  is  then  experienced  again  with  numerous 
fanciful  additions,  and  may  lead  to  acts  of  desperate  resist- 
ance and  violent  outcries.  The  scene  often  terminates  in 
a  convulsive  seizure.  Events  of  recent  occurrence  are 
also  repeated  occasionally  in  a  loquacious  manner,  but  in  a 
very  dreamy  state  of  consciousness ;  the  memory  of  this 
condition  is  then  very  imperfect. 

Finally,  we  may  mention  a  dream  state  which  occurs  in 
young  girls,  characterized  by  foolish  excitement  and  usually 
preceding  a  convulsive  seizure  by  a  few  hours.  Singing, 
laughing,  and  dancing  alternate  with  the  tendency  to  col- 
lect various  articles.  The  patients  are  usually  in  a  cheer- 
ful humor,  talk  impertinently,  do  all  sorts  of  foolish  and 
mischievous  acts,  imitate  animals.  They  do  not  recog- 
nize those  around  them,  and  have  only  an  imperfect  mem- 
ory of  the  condition. 

As  a  rule,  all  these  conditions  last  from  a  few  hours  to 
a  day,  but  the  mild  cases  are  sometimes  protracted  over 
several  weeks  or  months.  They  begin  and  end  quickly, 
their  course  is  variable,  and  at  times  the  impairment  of 
consciousness  may  disappear  almost  entirely,  while  the 
other  morbid  symptoms  remain  the  same,  but  are  not  rec- 
ognized as  such.  These  conditions  often  occur  after 
childbed,  severe  hemorrhages,  or  conditions  of  exhaustion 
in  general,  and  the  prognosis  is  then  comparatively  good. 
The  numerous  hallucinations  are  sometimes  interpreted  as 
indicative  of  good  or  bad  fortune,  but  on  account  of  the 


HYSTERICAL   INSANITY   PROPER.  31? 

impairment  of  consciousness  systematization  of  delusions 
is  rare.  At  all  events,  the  delusions  rapidly  disappear 
with  the  dream  states. 

Before  proceeding  to  the  discussion  of  hysterical  insanity 
proper,  it  must  be  mentioned  that  simple  forms  of  in- 
sanity may  also  occur  in  hysteria.  When  the  simple  in- 
sanity subsides,  the  hysterical  symptoms  may  then  persist. 
A  theatrical  demeanor  and  erotic  tinge  partially  obliterate 
the  clinical  history  of  simple  psychoses  in  an  hysterical 
individual. 

The  basis  of  hysterical  insanity  is  a  degeneration,  and 
can  be  regarded  as  a  mental  invalidism  which  imparts  to 
the  symptoms  of  the  psychosis  their  direction.  On  an 
hereditary  foundation  its  development  is  especially  un- 
favorable, and  it  then  often  progresses  steadily,  although 
sometimes  very  slowly,  to  dementia.  In  the  beginning 
the  fundamental  trait  of  hysterical  insanity  is  the  extreme 
sensitiveness  of  the  patient,  the  feeling  that  she  is  un- 
noticed, and  this  psychical  excitability  is  combined  in 
various  ways  with  the  numerous  symptoms  of  hysteria.. 
When  we  hear  constant  complaints  of  neglect  although 
the  most  sympathetic  love  is  exerted  in  order  to  gratify 
the  slightest  wish,  a  suspicion  of  beginning  weakness  of 
judgment  is  justified,  and  this  is  confirmed  by  the  steady 
advance  to  more  or  less  severe  degrees  of  dementia.  The 
numerous  disorders  of  sensation  and  other  hallucinations 
interfere,  from  the  start,  with  a  quiet  judgment  by  the 
patient  concerning  her  own  condition,  and  thus  they  are 
rapidly  converted  into  delusions.  At  first  the  vividness  of 
the  ideas  gives  rise  to  a  system  which  is  intended  to  ex- 
plain the  depressed  feelings,  but  this  soon  passes  into 
confusion  or  dementia. 

The  condition  does  not  progress  steadily,  but  by  fits  and 
starts.  It  is  often  accompanied  by  shameless  sexual  im- 
pulses, together  with  olfactory  hallucinations  and  religious 
ideas.  Hysterical  insanity  is  chronic  and  progressive, 
unlike  the  milder  conditions  of  a  similar  nature  in  simple 
hysteria,   in  which  the   individual    attack   runs  a  brief 


318  HANDBOOK    OF   INSANITY. 

course  without  notable  injury  to  the  intelligence.  It  is 
distinguished  from  simple  paranoia  by  the  striking  com- 
bination, at  the  onset,  of  psychical  excitability  and  mor- 
tified self-love,  and  by  the  fact  that  the  wild  current  of  sen- 
sory disorders  is  interpreted  without  judgment ;  the  course 
is  usually  more  rapid,  and  the  union  of  sexual,  religious, 
and  olfactory  disturbances  is  peculiar  to  hysterical  in- 
sanity. 

Another  form  of  hysterical  insanity  is  unattended  with 
hallucinations  or  they  play  a  very  subordinate  part.  Here 
the  main  feature  is  the  patient's  attempt  to  find  in  ex- 
ternal influences  an  explanation  for  her  own  morbidly 
exalted  or  depressed  mood.  Great  facility  of  speech, 
which  often  passes  into  a  certain  dialectic  skill,  is  often 
associated  with  this  condition,  in  which  the  patient  is  ab- 
sorbed utterly  in  her  own  interests  and  is  incapable  of  fol- 
lowing foreign  interests.  In  addition,  there  are  numer- 
ous physical  symptoms  which  can  merely  be  referred  to 
(motor  and  sensory  paralyses,  narrowing  of  the  field  of 
vision,  disorders  of  secretion). 

Even  attempts  at  suicide  may  be  made  as  the  result  of 
desperation.  Usually,  however,  they  are  not  meant  seri- 
ously, although  by  accident  they  may  terminate  fatally. 
Hence,  necessary  precautions  must  not  be  omitted  even  in 
an  asylum,  although  we  ought  to  appear  indifferent  to  the 
suicidal  attempt.  This  form  rarely  terminates  in  demen- 
tia, while  the  higher  feelings  are  lost  in  the  growing  self- 
ishness. In  these  persons  we  not  alone  observe  sexual 
excesses  carried  out  in  an  impulsive  manner,  but  also  the 
theft  of  valuables  from  shops  and  friends. 

The  course  of  all  the  mental  disorders  which  are  as- 
sociated with  hysteria  may  be  extremely  variable.  If  the 
mental  disturbance  occurs  in  paroxysms,  the  chances  of 
recovery  of  the  individual  attack  are  favorable,  although 
relapses  and  new  attacks  are  probable.  But  the  hysterical 
change  of  character  and  protracted  hysterical  insanity  may 
lead  to  permanent  progressive  conditions.  The  danger 
of  terminal  dementia  is  greatest  in  very  young  people,  but 


TREATMENT.  319 

is  much  rarer  than  in  epileptic  insanity.  On  the  whole, 
the  prognosis  of  the  mental  disorders  of  hysteria  is  un- 
favorable, despite  the  probability  of  the  subsidence  of  the 
individual  attacks.  When  the  sexual  life  plays  an  un- 
deniable part,  considerable  improvement  sometimes  occurs 
at  the  menopause  or  after  removal  of  local  irritation. 
Otherwise  the  hysterical  character,  at  least,  remains  until 
the  end  of  life,  or,  in  severe  cases,  more  or  less  pronounced 
dementia  gradually  develops. 

Treatment  offers  the  best  chances  of  success  when  we 
can  succeed  in  removing  the  causes.  Treatment  of  the  in- 
dividual symptoms  is  less  successful  because  the  patients 
must  not  be  allowed  to  notice  that  we  regard  them  as 
mentally  diseased.  If  conditions  of  mental  or  bodily  ex- 
haustion are  present,  these  must  be  relieved  and  renewed 
vigor  restored  to  the  exhausted  nervous  system.  This 
usually  requires,  above  all  else,  the  removal  of  the  patient 
from  her  accustomed  environment  and  her  transfer  to 
surroundings  in  which  she  is  compelled  to  recognize  the 
mild  authority  of  another.  In  many  cases  tbe  personal 
influence  of  the  physician  may  be  even  more  important, 
as  is  evident  from  the  well-known  effects  of  suggestion  in 
hysteria.  This  factor  is  more  important,  however,  in  sim- 
ple hysteria  with  slight  change  of  character  than  in  cases 
in  which  the  mental  disorders  are  more  marked.  But 
suggestion  may  only  be  employed  by  the  mild  means  of 
personal  authority,  not  as  hypnosis  proper.  The  un- 
shakable faith  which  the  physician  acquires  through  ear- 
nest sympathy  thus  becomes  one  of  his  most  effective 
auxiliaries. 

The  bodily  exhaustion  is  to  be  treated  according  to  gen- 
eral principles.  Thus,  the  rest  cure,  electricity,  cautious 
cool  douching  after  lukewarm  baths,  etc.,  may  be  valu- 
able in  combating  prominent  symptoms.  Potassium  bro- 
mide is  not  as  effective  as  in  epilepsy.  It  may  possibly 
secure  sleep  by  diminishing  the  nervous  excitement,  but 
its  administration  is  contra-indicated  in  conditions  which 
exhibit  a  tendency  to  hypnotic  phenomena.      Finally,  we 


320  HANDBOOK   OF   INSANITY. 

must  warn  against  the  protracted  use  of  morphine  because 
the  patients  too  often  succumb  to  the  morphine  habit. 

Proper  psychical  treatment  under  favorable  external  sur- 
roundings and  good  nursing  are  therefore  the  best  reme- 
dies. This  is  especially  evident  in  the  occasionally  almost 
epidemic  occurrence  of  hysterical  affections  in  which  men- 
tal disturbances  play  a  prominent  part.  In  the  similar 
conditions  which  develop  occasionally  in  schools  at  the 
present  time,  recovery  usually  ensues  very  rapidly  when 
the  patients  are  separated  from  one  another. 

The  spasmodic  phenomena  which  occur  in  such  epidemics 
are  sometimes  associated  with  others  which  resemble 
chorea.  Indeed,  mental  disorders  may  occur  in  chorea 
and  show  that  this  neurosis  is  constitutional.  But  these 
disorders  are  too  varied  to  permit  the  establishment  of  a 
special  disease  known  as  choreic  insanity. 

G.    MENTAL   DISORDERS   WITH   NEURASTHENIA. 

Chronic  Forms. 

In  this  class  extensive  spasmodic  symptoms  are  almost 
always  absent,  but  great  irritability  and  weakness  of  the 
entire  nervous  system  occupy  the  attention  of  the  patient 
so  that  he  becomes  a  constant  observer  of  all  his  manifold 
symptoms.  The  mental  disorders  associated  with  neuras- 
thenia are  very  numerous,  and  include  many  conditions 
which  are  on  the  border  line  of  insanity,  and  also  the 
greater  part  of  those  morbid  conditions  which  are  known 
as  hypochondria.  The  latter  term  has  lost  its  original 
meaning  and  should  now  be  applied  only  to  designate  in- 
dividual symptoms. 

Neurasthenia  may  be  congenital  or  acquired.  Many 
of  its  symptoms  are  found  in  other  psychoses  if  they  have 
developed  on  a  neurasthenic  basis.  Here  we  will  first 
consider  those  symptoms  which  possess  a  certain  inde- 
pendence and  at  the  same  time  a  more  intimate  connection 
with  the  course  of  mental  processes. 

The  main  features  of  congenital  and  acquired  neuras- 


INCREASED   EXCITABILITY.  321 

thenia  are  the  extreme  readiness  of  response  and  the  rapid 
exhaustion  of  the  nervous  and  mental  functions. 

The  mental  disorders  associated  with  neurasthenia  do 
not  occur  in  paroxysms.  Their  development  and  course  are 
slow  and  gradual  and  continue,  with  slight  changes,  for  a 
long  time.  A  constantly  recurring  feature  is  the  feeling  of 
prostration  of  the  bodily  and  mental  vigor.  In  moments 
of  excitement  neurasthenics  are  inclined  to  attribute  their 
irritable  mood  to  every  possible  external  circumstance,  but 
with  the  return  of  the  general  nervous  exhaustion  the  in- 
sight into  the  connection  between  their  mood  and  their  own 
conduct  also  returns.  The  feeling  of  being  sick  does  not 
follow  reflection,  but  is  imperative.  The  morbid  element 
in  the  mental  condition  of  these  patients  often  consists  of 
the  very  fact  that  this  feeling  of  being  sick  is  not  suffi- 
ciently explained  by  other  conditions  of  the  body.  Al- 
though we  will  meet  numerous  bodily  symptoms  which 
now  and  then  lie  at  the  foundation  of  the  general  condi- 
tion and  give  it  its  general  direction,  this  connection  is 
not  the  rule. 

The  increased  mental  irritability  is  not  alone  too  great, 
but  is  also  too  protracted,  and  a  combination  of  increase 
and  diminution  of  irritability  over  limited  fields  is  un- 
deniable. There  is  thus  an  absence  of  symmetry  in  the 
conduct  of  these  individuals  which  cannot  be  concealed  by 
the  great  self-control  that  is  occasionally  present.  This 
may  be  true  of  the  higher  feelings  as  shown,  for  example, 
in  excessive  love  and  affection  for  others,  or  in  the  slight 
power  of  endurance  in  mental  work,  while  even  difficult 
mental  processes  are  grasped  at  once  with  great  ease. 
These  conditions  are  sometimes  subject  to  irregular 
changes. 

In  comparatively  strong  natures  the  increased  excitabil- 
ity occupies  the  foreground,  in  weaker  natures  the  rapid 
exhaustion  becomes  more  prominent.  When  the  exci- 
tability becomes  blunted  with  increasing  exhaustion  men- 
tal decay  usually  sets  in,  while  the  excitability  disappears 
with  increasing  endurance  when  neurasthenic  conditions 
21 


322  HANDBOOK   OF   INSANITY. 

recover.  It  is  fortunate  for  such  individuals  when  their 
mental  development  is  slow,  because  recovery  of  the  fun- 
damental neurasthenic  condition  is  then  most  apt  to 
occur. 

We  have  already  said  that  one  of  the  most  important 
signs  of  the  mental  disorder  associated  with  neurasthenia 
is  the  manner  in  which  the  feelings,  thoughts,  and  actions 
of  the  patient  absorb  his  entire  attention,  and  we  will  now 
enter  a  little  more  closely  into  the  details  of  this  imperative 
thought.  By  this  term  we  mean  the  various  ways  in 
which  concepts,  feelings,  and  impulses  to  action  force 
themselves  irresistibly  upon  the  patient  and  overpower 
him.  We  may  accordingly  speak  of  imperative  sensations, 
notions,  and  acts.  In  a  measure  the  patient  has  lost  con- 
trol over  the  contents  of  his  consciousness.  A  thought 
presents  itself  to  him,  to  his  surprise,  without  any  connec- 
tion with  the  ideas  which  may  be  present  in  consciousness 
at  the  time,  or  it  follows  immediately  upon  the  sight  of  en- 
tirely irrelevant  external  objects.  A  constant  feature  is 
the  recognition  of  the  disorder  and  an  often  extremely 
distressing  feeling  of  compulsion. 

The  imperative  concept  is  rarely  independent.  If  it 
remains  simple  and  independent,  it  corresponds  usually 
to  a  single  idea.  A  single  word  constantly  thrusts  itself 
into  the  contents  of  consciousness,  or  the  notion  of  some 
entirely  foreign  object,  for  example,  a  water-closet,  or  the 
name  of  a  person  in  whom  the  patient  has  no  special  in- 
terest, continually  intrudes  in  the  most  annoying  manner. 
The  distressing  perception  of  this  compulsion  may  natu- 
rally arouse  fear  and  doubt  in  the  ordinary  psychological 
way,  so  that  these  cannot  be  called  imperative  notions ; 
but  even  apart  from  such  correct  inferences,  an  impera- 
tive notion  occasionally  becomes  associated  with  others 
along  the  path  entered  upon. 

A  frequent  illustration  of  these  associated  imperative 
notions  in  neurasthenics  is  the  notion  that  a  letter  has  not 
been  sealed,  and  this  impels  them  to  see  whether  the  letter, 
lying  on  the  desk,  is  still  open.     If  the  letter  has  already 


MORBID    FEARS.  323 

been  mailed,  the  fear  is  excited  that  others  might  read  its 
contents,  and  then  the  restlessness  impels  to  new  thoughts. 
Perhaps  this  or  that  expression  in  the  letter  looks  suspi- 
cious, a  new  letter  is  written  in  order  to  explain  matters  to 
the  recipient  and  to  beg  his  pardon,  and  then  the  distress- 
ing scene  may  begin  over  again  despite  the  most  careful 
supervision  of  the  correspondence.  Well  known,  likewise, 
is  the  notion  that  a  door  has  not  been  closed,  and  this 
leads  to  continued  reclosing,  although  the  individual  is 
fully  conscious  of  the  folly  of  his  conduct  and  is  even 
ashamed  of  it.  These  imperative  notions  may  develop 
during  the  most  varied  occupations.  The  notion  that  a 
light  has  not  been  extinguished  compels  the  patient  to  rise 
at  night  in  order  to  see  whether  the  light  has  really  been 
extinguished,  or  if  this  is  not  done,  the  fear  of  fire  is 
aroused  in  a  distressing  manner.  Indeed,  the  performance 
of  such  little  acts  after  these  notions  usually  offers  some 
relief,  at  least  for  the  time.  But  if  the  patient,  conscious 
of  the  morbid  nature  of  his  doubt,  does  violence  to  his 
feelings  and,  for  example,  fails  to  recount  a  sum  of  money 
which,  for  fear  of  miscounting,  he  has  already  counted  a 
number  of.  times,  then  the  accompanying  distressing  affect 
increases  and  bodily  feelings  of  an  annoying  character 
appear,  such  as  tremor,  palpitation,  acceleration  of  the 
pulse,  sweats,  and  diarrhoea.  Quite  a  frequent  phenomenon 
is  the  dread  of  touching  door-knobs  and  other  objects  to 
which  infectious  matters  might  possibly  have  adhered. 
Or  the  notion  that  a  bit  of  glass  or  a  sharp  splinter  of  bone 
may  be  concealed  in  the  food  leads  to  constantly  renewed 
examinations,  despite  the  knowledge  of  their  uselessness. 
The  patient  cannot  do  otherwise — he  cannot  escape  from 
the  notion.  One  individual  suddenh^  thinks  that  he  may 
soil  his  clothes  upon  the  street ;  this  is  followed  by  the 
notion  that  the  dirt  may  come  in  contact  with  his  body, 
excite  the  disgust  of  others,  or  fall  into  their  food ;  he  now 
avoids  all  contact  with  the  floor,  the  walls,  or  with  other 
people,  walks  only  on  tiptoe,  constantly  brushes  his  hands, 
etc. 


324  HANDBOOK    OF   INSANITY. 

Still  more  distressing  are  the  conditions  known  as  grue- 
belsucht  (vide  page  70) . 

"We  thus  approach  the  domain  of  hypochondriacal  com- 
plaints, which  depend  materially  upon  the  culture  and 
medical  views  of  the  patient.  The  dread  that  a  serious 
ailment  is  developing  finds  sufficient  grounds  in  bodily 
disorders  which  may  really  be  present  or  solely  in  the 
nervous  conditions  which  result  from  the  neurasthenic 
basis.  The  complaints  refer  mainly  to  the  fashionable 
diseases  which  are  then  attracting  most  attention.  Cholera 
and  influenza,  syphilis  and  phthisis  are  found  again  and 
again  in  the  reports  of  these  neurasthenics;  a  chronic 
pharyngitis  becomes  incipient  phthisis,  slight  eczema  is 
converted  into  syphilis,  etc.  The  demonstration  of  the 
absence  of  all  cause  for  alarm  does  not  relieve  the  patient, 
and  the  distressing  feeling  and  imperative  conception  of 
this  or  that  disease  again  makes  it  appearance.  This 
imperative  conception  dominates  the  scene,  while  the  nu- 
merous other  symptoms  which  result  from  the  primary 
taint  usually  become  subsidiary. 

The  feelings  called  forth  by  the  imperative  concept  do 
not  possess  the  vividness  and  duration  which  we  might 
be  led  to  expect ;  the  recognition  that  they  are  not  appro- 
priate constantly  becomes  evident  to  the  patient  himself. 
Hence  the  mood,  although  usually  inclined  to  irritability 
and  dissatisfaction,  is  very  variable  and  capricious,  and 
we  are  often  surprised  by  redeeming  traits,  among  which 
an  active  sympathy  is  the  most  attractive. 

Among  the  accompanying  bodily  symptoms  neuralgic 
pains  are  frequent.  One  of  the  most  frequent  complaints 
is  that  of  headache  of  the  most  varied  kinds,  over  the  en- 
tire head,  the  forehead,  or  occiput.  There  is  often  a  feel- 
ing of  heat  in  the  head,  and  not  infrequently  the  patient 
feels  rotary  movements  within  the  head.  These  feelings 
are  associated  with  a  certain  degree  of  interference  with 
thought,  although  this  is  not  so  distinct  in  reality  as  the 
patient  imagines.  The  rapid  exhaustion  after  mental  ef- 
fort increases  the  morbid  feelings  in  the  head.     Circum- 


SPINAL   IRRITABILITY.  325 

scribed  hyperesthesias  of  the  scalp  are  frequent,  and  even 
the  combing  of  the  hair  may  be  borne  with  difficulty. 

There  are  usually  irritative  phenomena  in  other  sen- 
sory tracts,  dependent  on  great  sensitiveness  to  external 
impressions.  Flashes  of  light,  tinnitus,  and  other  subjec- 
tive phenomena  alternate  with  one  another.  The  hyperes- 
thesia to  light  sometimes  causes  great  suffering,  especially 
if  accompanied  by  attacks  in  which  specks  and  flashes  of 
light  fill  the  field  of  vision.  We  also  find  liking  for  or 
antipathy  to  certain  forms  of  smell  and  taste.  The  pa- 
tients may  suffer  from  loud  noises,  and  even  their  own 
voices  may  produce  an  intolerable  sound. 

This  irritability  of  the  senses  is  combined  not  infre- 
quently with  great  subjective  weakness  and  rapid  exhaus- 
tion, so  that  the  field  of  vision  soon  becomes  obscure  or 
hearing  becomes  indistinct.  The  same  mixture  of  exces- 
sive irritability  and  exhaustion  is  found  in  the  muscles 
and  viscera.  The  patients  often  complain  of  heaviness 
and  a  tired  feeling  in  the  limbs  after  slight  exertion,  and 
of  numbness,  pricking,  and  formication.  A  common 
symptom  is  the  feeling  of  painful  exhaustion  in  the  neck 
and  back ;  it  may  appear  spontaneously,  on  pressure,  or  on 
motion.  When  there  is  also  hyperesthesia  of  the  spinous 
processes  the  entire  condition  is  known  as  spinal  irrita- 
tion. Muscular  restlessness  may  also  become  one  of  the 
most  distressing  of  all  the  symptoms.  ISTow  and  then  there 
may  be  a  spasm  of  this  or  that  muscle,  especially  in  the 
legs,  but  general  spasms  are  not  observed.  Fibrillary 
twitchings  occur,  particularly  in  the  facial  muscles,  and 
this  symptom  may  be  important  in  the  differential  diag- 
nosis between  dementia  paralytica  and  neurasthenia. 
The  paretic  does  not  notice  the  twitchings;  the  neuras- 
thenic devotes  his  entire  attention  to  them.  The  latter  also 
notices,  with  dread,  slight  disturbances  of  speech,  espe- 
cially the  use  of  wrong  words  during  excitement. 

A  description  of  the  hypochondriacal  complaints  con- 
cerning digestion  would  lead  us  too  far ;  other  organs  also 
give  rise  to  numerous  symptoms.     Of  much  greater  im- 


326  HANDBOOK   OF   INSANITY. 

portance  are  the  disorders  of  the  blood-vessels  and  the 
circulation.  Palpitation  of  the  heart  may  be  so  severe 
that  the  patient  feels  and  hears  the  cardiac  impulses ;  to 
this  is  generally  added  a  feeling  of  fright  and  restlessness, 
which  is  apt  to  be  followed  by  slight  hypochondriacal  de- 
lusions. Such  attacks  may  be  associated  with  dilatation 
of  the  left  pupil,  and  it  is  probable  that  both  symptoms  are 
due  to  irritation  of  the  sympathetic  nerve.  Paralyses 
of  the  sympathetic  occur  very  often  in  neurasthenia. 
Blushing  when  surprised  or  when  spoken  to  is  one  of  the 
most  annoying  complaints  of  the  neurasthenic,  and  is 
aggravated  when  they  concentrate  their  attention  upon  it. 

Paroxysmal  attacks  of  heat  and  throbbing  of  the  vessels 
may  occur  over  the  entire  body.  These  sensations  are 
extremely  annoying  because  they  also  extend  to  the  inter- 
nal organs  and  give  rise  to  distressing  restlessness.  These 
conditions,  which  occur  especially  after  emotional  excite- 
ment, show  that  the  entire  central  nervous  system  is 
irritable  and  rapidly  exhausted,  and  also  enable  us  to 
understand  other  peculiar  neurasthenic  conditions.  We 
know  that  the  feeling  of  fear  is  accompanied,  as  a  rule, 
by  irritation  and  paralysis  of  the  vasomotor  system,  and 
that  feelings  of  vertigo  develop  in  a  similar  connection 
with  the  vasomotors.  It  is  very  probable,  therefore,  that 
implication  of  the  sympathetic  explains  the  various  forms 
of  morbid  fears  in  neurasthenia.  It  must  be  admitted, 
however,  that  visible  symptoms  on  the  part  of  the  vascular 
system  are  not  always  present.  But  that  these  conditions 
do  result  from  vascular  changes  is  shown  by  the  fact  that 
they  are  usually  attended  by  more  or  less  severe  vertigo. 

The  morbid  fears  which  will  now  be  discussed  are  ob- 
served, as  a  rule,  after  definite  causes.  The  most  com- 
mon form  is  the  fear  of  places  which  develops  upon  en- 
tering a  square,  an  empty  street,  or  a  lonesome  region. 
The  patient  is  suddenly  attacked  by  the  fear  that  his 
strength  will  leave  him  and  that  he  will  be  unable  to  walk 
farther.  This  is  accompanied  by  a  feeling  of  oppression, 
palpitation,  constriction  of  the  throat,  an  outbreak  of  cold 


FEAR    OF    PLACES.  327 

sweat,  with  tremor  and  weakness  of  the  legs.  If  the  pa- 
tient turns  about  or  succeeds  in  reaching  a  side  row  of 
houses,  the  feeling  of  fear  disappears.  The  condition  is 
accompanied  by  a  mere  indefinite  fear  of  some  impending 
danger,  and  is  often  overcome  by  the  company  of  any  per- 
son who  happens  to  pass.  Height  vertigo  may  develop 
with  similar  symptoms  sometimes  if  the  patient  is  seated 
alone  near  a  high  window,  while  he  is  perhaps  able,  in 
company,  to  climb  a  steep  cliff.  Repetition  increases  the 
severity  of  the  attacks  as  a  rule,  and  hence  the  dread  of 
a  similar  position  facilitates  their  occurrence.  In  other 
words,  mental  irritability  must  be  combined  with  weak- 
ness of  the  vasomotor  system  in  order  to  produce  such 
conditions.  The  same  combination  probably  obtains  in 
other  allied  conditions,  such  as  fear  of  crowds  or  of  closed 
rooms.  After  the  attack  has  subsided  the  patients  some- 
times laugh  at  their  own  folly,  but  are  unable  to  repress 
the  fear  on  the  next  occasion.  The  fear  is  a  true  impera- 
tive feeling. 

In  this  connection  we  may  mention  imperative  acts  so 
far  as  they  are  independent  and  not  related  in  thought  to 
fears  or  delusions.  Some  homicides,  thefts,  rapes,  etc., 
seem  to  be  explicable  in  this  manner,  although  in  many 
of  these  cases  careful  examination  shows  that  the  acts  are 
based  on  hallucinations  or  delusions.  When  the  latter  are 
absent  we  usually  find  an  honest  attempt  on  the  part  of 
the  patient  to  struggle  against  the  morbid  impulse,  which 
appears  incomprehensible  to  him. 

But  all  the  symptoms  mentioned  do  not  lead  to  a  gen- 
eral change  of  mental  life  which  may  be  regarded  as  neu- 
rasthenic insanity.  It  is  merely  to  be  noted  that  various 
forms  of  insanity,  such  as  mania,  melancholia,  paranoia, 
dementia  paralytica,  present  a  peculiar  appearance  when 
they  develop  upon  a  neurasthenic  basis.  Indeed,  it  would 
be  preferable  to  discuss  the  condition  in  the  section  on 
general  symptomatology,  were  it  not  for  the  fact  that  the 
mental  phenomena  of  neurasthenia  possess  such  great 
clinical  importance. 


328  HANDBOOK   OF  INSANITY. 

The  causes  of  neurasthenia  include  all  those  which  give 
rise  to  mental  and  nervous  diseases  in  general  and  which 
are  shown  in  exhaustion  of  the  entire  nervous  system. 
An  important  cause  is  mental  strain  associated  with  a 
sense  of  responsibility  in  a  position  of  influence.  Hence 
active  talented  men  of  prominence  are  especially  prone 
to  this  affection.  Otherwise  the  female  sex  predominates 
on  account  of  its  greater  emotional  excitability  and  dimin- 
ished power  of  resistance.  Youth  entails  some  danger 
form  overwork  in  school.  At  the  period  of  puberty,  pre- 
mature development  of  the  sexual  sense  with  excessive 
masturbation  gives  rise  to  exhaustion.  Cases  of  neuras- 
thenia again  grow  more  numerous  at  the  menopause  and 
also  at  the  period  of  senile  involution.  Middle  life  is  most 
endangered  by  the  external  conditions.  Sedentary  habits 
(in  officials,  merchants,  students)  and  continued  dissipa- 
tion are  frequent  factors.  Insomnia  is  also  a  very  prom- 
inent cause.  Exhausting  diseases  of  all  kinds,  whether 
acute  or  chronic,  lead  to  the  development  of  neurasthenic 
conditions. 

The  course  of  the  mental  disorders  of  neurasthenia  is 
rarely  uniform.  As  a  general  thing  they  develop  slowly ; 
more  rarely  they  occur  suddenly  after  exhausting  diseases. 
The  variations  in  their  course  are  usually  not  dependent 
on  external  causes;  improvement  and  exacerbation  may 
occur  with  equal  surprising  rapidity.  A  word  or  look 
may  suffice  to  make  the  patient  feel  worse.  The  influence 
of  the  weather  is  manifold  and  varies  in  every  case.  The 
subsidence  of  all  symptoms  is  sometimes  so  marked  that 
the  disease  is  not  noticeable  for  months  or  even  years. 
In  the  majority  of  cases  the  disease  lasts  until  the  end  of 
life,  though  complete  recovery  has  been  observed  in  a  few 
cases. 

The  prognosis  of  the  mental  disorders  of  neurasthenia  is 
more  favorable  when  the  condition  is  due  to  demonstrable 
external  agencies.  Cases  in  which  imperative  feelings 
occur  are  more  favorable  than  those  in  which  there  are 
imperative  ideas.     Neurasthenia,  per  se,  does  not  lead  to 


DIAGNOSIS.  329 

dementia,  but  this  termination  may  occur  in  any  other 
psychosis  which  develops  on  a  neurasthenic  basis. 

The  diagnosis  of  neurasthenia  as  the  basis  of  an  existing 
mental  disorder  may  be  extremely  important  to  the  prac- 
titioner. He  must  differentiate  the  affection  from  some 
other  psychosis  or  severe  disease  of  the  nervous  system 
and  from  dementia  paralytica. 

The  depression  of  a  beginning  psychosis  is  more  pro- 
nounced than  that  of  neurasthenia  and  is  not  relieved  so 
easily  by  external  stimulation.  For  a  long  time  it  may 
be  difficult  to  exclude  organic  nervous  diseases,  such  as 
focal  lesions  of  the  brain,  diffuse  sclerosis,  tabes,  and  the 
differential  diagnosis  can  only  be  made  after  prolonged  ob- 
servation. 

Most  important,  however,  is  the  differentiation  of  neu- 
rasthenia from  beginning  paralytic  dementia.  The  main 
feature  of  the  latter  is  the  impairment  of  judgment  ad- 
vancing to  dementia,  but  the  mental  weakness  of  the 
neurasthenic  is  merely  a  ready  exhaustion,  while  the 
judgment  of  external  circumstances  is  not  materially  af- 
fected so  long  as  they  do  not  refer  to  conditions  within  the 
patient's  own  body.  In  the  latter  event  the  patient  ob- 
serves himself  with  morbid  care,  while  the  paralytic  pays 
no  attention.  This  is  very  evident  in  the  case  of  speech  dis- 
orders which,  in  neurasthenics,  may  give  rise  to  the  fear 
of  impending  dementia  paralytica.  In  the  latter  affection, 
however,  they  are  unnoticed  or  disregarded  by  the  patient. 
Other  motor  disorders,  such  as  contraction  or  inequality 
of  the  pupils,  tremor  of  the  hands  and  legs,  may  occur  in 
both  affections,  but  are  less  frequent  and  persistent  in  neu- 
rasthenia. Furthermore,  imperative  thoughts  are  not 
met  with  in  paresis.  In  advanced  dementia  a  mistake  is 
no  longer  possible. 

The  discussion  of  the  treatment  of  neurasthenia  does  not 
come  within  the  scope  of  a  work  on  insanity,  but  many  use- 
ful hints  will  be  found  in  the  general  section  on  treatment. 
It  may  here  be  remarked,  however,  that  the  neurasthenic 
often  derives  more  benefit  from  travel  than  from  a  stay  in 


330  HANDBOOK   OF   INSANITY. 

an  institution.  When  disease  is  associated  with  pro- 
nounced chronic  mental  disorders,  the  treatment,  in  the 
main,  must  be  directed  against  the  latter. . 

Acute  Forms. 

Acute  forms  of  neurasthenia  are  always  acquired  and 
follow  immediately  upon  certain  definite  causes.  They  are 
conditions  of  exhaustion  of  the  nervous  system  in  which 
the  implication  of  the  mental  processes  is  the  main  factor. 
They  afford  a  transition  to  the  succeeding  group  of  toxse- 
mias  in  which  the  morbific  cause  acts  even  at  the  moment 
of  the  development  of  the  disease.  The  relation  between 
the  two  groups  is  also  shown  by  the  fact  that  certain  of 
these  exhaustive  conditions,  viz.,  febrile  delirium,  are  at- 
tributed to  an  organized  virus.  Indeed,  it  is  doubtful 
whether  some  of  the  mental  disturbances  of  infectious  dis- 
eases are  not  due  directly  to  such  a  virus,  and  that  the  in- 
crease of  temperature  has  no  effect.  On  the  other  hand, 
sudden  febrile  conditions,  which  depend  on  irritability  of 
the  exhausted  nervous  system,  are  sometimes  observed  in 
protracted  and  exhausting  constitutional  diseases.  Per- 
haps chemical  poisons  produced  within  the  body  play  a 
part  in  such  cases.  We  refer  here  mainly  to  those  con- 
ditions which  develop  after  the  termination  of  an  infec- 
tion. They  may  appear  at  the  close  of  an  exhausting  febrile 
disease,  or  a  little  later  when  exhaustion  becomes  more 
distinct  during  convalescence.  We  may  also  mention 
those  conditions  in  which  the  nervous  exhaustion  is  due 
to  imperfect  nutrition,  as  in  shipwrecked  individuals,  etc. 
The  delirium  of  dying  individuals  is  allied  to  these  con- 
ditions. 

The  lassitude  after  sleepless  nights,  accompanied  by 
grave  cares  and  worry,  and  after  excessive  mental  work, 
may  be  the  cause  of  acute  neurasthenia  in  which  a  dreamy 
impairment  of  consciousness  may  be  the  chief  element  of 
the  mental  disorder.  There  is  an  inability  on  the  part  of 
the  patient  to  realize  clearly  his  impressions  from  sur- 


ACUTE   NEURASTHENIA.  331 

rounding  circumstances  and  also  his  own  thoughts.  He 
finds  himself  in  a  state  of  complete  helplessness  and  be- 
comes restless  and  anxious,  because  all  external  impressions 
have  an  uncanny  character.  His  utterances  are  corre- 
spondingly confused,  and  indeed  the  entire  condition  has 
been  described  as  asthenic  confusion.  The  confused  fear 
leads  occasionally  to  dreamy  irrational  acts  which  have 
an  undeniable  resemblance  to  those  committed  on  an  epi- 
leptic basis.  This  resemblance  is  so  much  more  important 
clinically,  because  after  the  act  there  is  usually  a  greater 
or  less  defect  of  memory  and  occasionally  a  temporary 
complete  loss  of  consciousness.  That  this  condition  is 
due  to  exhaustion  of  the  brain  is  evident  from  the  fact 
that  rapid  and  complete  restoration  follows  sleep  and 
improved  nutrition.  It  need  merely  be  mentioned  that 
the  combination  with  hallucinations  and  delusions  may 
give  rise  to  morbid  conditions  which  correspond  to  other 
psychoses,  but  these  do  not  belong  necessarily  to  the  ex- 
haustion of  the  brain  now  under  discussion.  Even  in 
these  cases  complete  recovery  usually  occurs  in  a  few 
weeks  if  the  patient  is  transferred  to  better  surroundings 
and  secures  sufficient  sleep.  The  transition  to  dementia 
is  rare ;  the  termination  in  death  from  progressive  bodily 
exhaustion  is  more  frequent. 

The  relation  to  bodily  exhaustion  is  still  more  distinct 
in  those  forms  of  acute  neurasthenia  which  directly  follow 
profuse  losses  of  blood,  difficult  childbed,  and  other  ex- 
hausting conditions.  As  a  general  thing,  hallucinations 
are  then  more  prominent.  Upon  them  depend,  in  the 
main,  the  confusion  and  anxious  mood  which  lead  not  in- 
frequently to  sudden  acts  of  violence,  especially  suicide, 
and  to  sudden  running  away.  These  conditions  last  a  few 
days  and  usually  terminate  as  suddenly  as  they  began; 
but  irritability  and  weakness  of  memory  may  continue  for 
some  time.  The  danger  consists  in  the  sudden  failure  of 
the  vital  energies,  which  must  be  combated  by  stimulants 
(wine,  whiske}r,  camphor) ,  hypnotics,  and  proper  feeding. 

Finally,  acute  conditions  of  a  similar  nature  may  follow 


332  HANDBOOK   OF   INSANITY. 

sexual  excesses  of  all  kinds.  Here  again  the  combina- 
tion of  religious  delusions  and  nauseous  olfactory  halluci- 
nations dominates  the  clinical  history.  The  prognosis  is 
also  favorable  if  the  general  condition  can  be  improved 
and  the  causes  removed. 

H.    MENTAL   DISORDERS   DUE   TO   POISONS. 

A  certain  class  of  mental  disorders  is  due  to  the  action 
of  poisons  which  enter  the  body  from  without.  In  a  text- 
book on  insanity  we  cannot  enter  in  detail  into  a  descrip- 
tion of  the  various  forms  of  poisoning,  but  some  of  the 
more  important  symptoms  will  be  considered,  inasmuch 
as  the  practitioner  may  be  placed  in  such  a  position  that 
he  is  compelled  to  infer  the  causal  poisoning  from  the 
mental  symptoms  alone. 

These  conditions  develop  either  after  a  single  severe  at- 
tack of  poisoning  or  after  the  protracted  and  constant  ad- 
ministration of  poisonous  substances.  The  action  of  alco- 
hol will  chiefly  concern  us  in  both  forms.  Striking 
mental  changes  may  also  occur  after  a  few  other  rapidly 
developing  poisonings.  After  carbonic-oxide  inhalations, 
a  preliminary  period  of  unconsciousness  is  followed  for 
days  by  a  condition  of  confusion  which  is  distinguished 
with  difficulty  from  similar  conditions,  unless  the  previ- 
ous history  is  known.  A  notable  feature,  however,  is  the 
absence  of  hallucinations,  and  violent  headache  is  also 
very  striking.  During  the  period  of  complete  unconscious- 
ness the  diagnosis  depends  upon  the  other  toxic  symp- 
toms, as  described  in  treatises  on  toxicology. 

When  delirium  occurs  in  the  conditions  of  unconscious- 
ness produced  by  the  so-called  anaesthetics,  it  is  generally 
of  a  cheerful  character,  occasionally  with  a  sexual  coloring 
as  in  nitrous-oxide  anaesthesia.  It  resembles  the  acute  in- 
toxications after  taking  opium  and  hasheesh.  Fantastic 
hallucinations  are  very  numerous  in  these  forms. 

The  higher  mental  activities  suffer  so  much  more 
markedly   the  more  often  the  poisonous  substance  acts. 


MORPHINISM.  333" 

Among  the  anaesthetics,  sulphide  of  carbon  is  still  to  be 
considered  in  this  respect.  After  some  prodromes  of  an 
indefinite  nature,  such  as  pressure  and  pain  in  the  head,  a 
feeling  of  dizziness  and  dulness,  a  more  or  less  distinct 
condition  of  excitement  develops  after  the  poison  has  been 
acting  for  a  few  weeks.  The  individual  becomes  very 
lively,  talkative,  and  irritable,  sexual  desire  is  increased, 
and  occasionally  the  appetite  becomes  insatiable.  At  in- 
tervals there  is  a  temporary  depressed  mood ;  then  mem- 
ory becomes  distinctly  impaired  in  many  until  they  become 
irrational,  and  at  the  same  time  speech  is  stuttering  and 
the  tongue  is  moved  with  difficulty.  Impairment  of  vision 
and  ringing  in  the  ears  are  also  observed.  Spasms  and 
fibrillary  twitchings  in  different  muscles  are  rarely  absent 
entirely,  and  these,  combined  with  great  muscular  weak- 
ness, present  a  picture  which  somewhat  resembles  demen- 
tia paralytica.  This  possibility  must  be  kept  in  mind  in 
the  vicinity  of  India-rubber  factories,  and  the  patients  can 
then  be  guarded  against  relapses  by  permanent  removal, 
from  the  injurious  occupation. 

Dementia  paralytica  may  also  be  suspected  in  poisoning 
with  iodine  and  bromine,  in  lead  encephalopathy,  and  in 
mercury  psychoses.  We  may  also  remind  the  reader  of  the 
violent  delirium  of  acute  phosphorus-poisoning.  A  little 
more  attention  must  be  devoted  to  the  action  of  morphine. 

Morphinism,  or  the  morphine  habit,  results  from  the  re- 
peated abuse  of  the  drug.  As  a  rule,  it  is  first  taken 
under  medical  supervision  in  order  to  relieve  various 
painful  affections.  When  injected  under  the  skin  it  pro- 
duces such  an  excellent  sedative  and  hypnotic  action  that 
a  desire  arises  for  the  repetition  of  this  effect,  especially 
as  it  is  often  associated  with  dreams  of  an  agreeable  char- 
acter. When  given  during  periods  of  exhaustion  mor- 
phine produces  greater  activity  and  a  general  feeling  of 
well-being.  Gradually  it  becomes  indispensable,  and  at  the 
same  time  the  dose  must  be  increased  to  produce  the 
desired  effect,  until  finally  2.0-3.0  may  be  taken  daily. 

The  mental  symptoms  may  be  due  directly  to  the  use  of. 


334  HANDBOOK   OF   INSANITY. 

the  drug,  while  other  so-called  abstinence  symptoms  follow 
its  withdrawal.  The  former  include  a  striking  change  of 
character;  irritable,  morose,  misanthropic,  the  patient 
grows  more  and  more  indifferent  to  outside  interests  and 
becomes  more  and  more  selfish,  until  finally  all  his  desires 
turn  around  the  satisfaction  of  his  hunger  for  morphine, 
which  gradually  loses  its  pleasant  effects.  As  a  rule,  the 
mental  disorders  are  confined  to  the  domain  of  ethical 
ideas,  while  intelligence  is  affected  only  in  so  far  as  the 
memory  and  power  of  endurance  in  mental  work  are  con- 
cerned. Chronic  morphinism  hardly  ever  leads  to  de- 
mentia, and  when  this  appears  to  be  the  case  another 
psychosis  should  be  suspected.  In  every  case,  however, 
there  is  a  diminution  of  resolution  and  power  of  action. 
At  times,  especially  during  the  periods  of  abstinence, 
hallucinations  occur,  often  combined  with  feelings  of  fear. 

The  bodily  symptoms  of  morphinism  will  not  be  de- 
scribed here;  they  may  be  found  in  any  text-book  of 
neurology. 

It  is  important  to  remember,  in  regard  to  the  diagnosis 
of  doubtful  cases,  that  the  morphine  is  excreted  in  the 
urine,  where  it  may  be  found  by  chemical  tests. 

The  term  alcoholism  is  applied  to  all  the  morbid  condi- 
tions which  are  due  to  the  abuse  of  alcoholic  drinks.  It  is 
to  be  kept  in  mind,  however,  that  the  alcoholic  basis  of 
some  psychoses  merely  gives  to  them  a  special  coloring, 
but  that  they  do  not  forfeit  their  own  characteristics. 

The  simplest  form  of  alcoholism,  viz.,  an  attack  of 
drunkenness,  shows  some  of  the  most  important  elements 
of  the  disease.  The  mental  processes  appear  to  be  accel- 
erated and  facilitated  in  a  fit  of  drunkenness.  The  increased 
self-esteem  leads  to  boldness  and  jollity.  At  first  the 
bodily  powers  are  also  increased.  Increased  necessity  for 
movement  is  shown  by  singing,  screaming,  laughing, 
dancing,  and  increased  sexual  desire  is  not  infrequent. 
In  a  little  while,  however,  the  individual  finds  it  difficult 
to  concentrate  his  attention  upon  internal  as  well  as  ex- 
ternal processes ;  the  interpretation  of  external  impressions 


DRUNKENNESS.  335 

also  becomes  slower.  The  aesthetic  feelings  and  ideas 
are  first  extinguished  in  the  drunken  man,  although  he  still 
retains  and  expresses  the  feeling  of  increased  power.  This 
offers  a  marked  contrast  to  his  foolish  actions.  A  char- 
acteristic feature  is  his  denial  of  his  excited  condition  and 
its  cause.  Not  infrequently  there  is  an  unfounded  change 
of  mood  from  joviality  to  depression.  With  the  constantly 
increasing  loss  of  the  power  of  attention,  the  individual 
enters  the  condition  of  complete  drunkenness.  During 
the  transition  deceptions  of  the  senses  may  be  manifested ; 
as  a  rule,  these  are  illusions,  not  true  hallucinations. 
Consciousness  is  lost  more  and  more,  and  while  speech 
becomes  confused,  motor  disorders  of  various  kinds  end 
the  scene. 

A  termination  in  conditions  which  resemble  dementia 
after  passing  through  excitement  of  all  the  mental  func- 
tions, accompanied  by  changes  of  mood  and  early  disap- 
pearance of  ethical  feelings,  by  a  tendency  to  denial  of 
drunkenness,  by  sexual  excitement,  hallucinations,  and 
motor  disorders — all  these  symptoms,  either  separately  or 
combined,  form  part  of  chronic  alcoholism.  As  a  matter 
of  course  there  are  numerous  transitions  between  the  sin- 
gle drunken  fit  and  the  symptoms  of  chronic  alcoholism. 
The  fact  that  severe  conditions  of  drunkenness  develop 
in  some  individuals  after  taking  very  small  amounts  of 
alcohol  shows  that  these  persons,  whether  as  the  result  of 
heredity  or  of  acquired  diminution  of  mental  vitality,  are 
less  capable  of  resistance  and  have  a  predisposition  to 
mental  disturbances,  whatever  may  be  the  exciting  cause. 

In  such  individuals  there  is  a  tendency  to  the  devel- 
opment of  numerous  hallucinations,  especially  of  sight. 
These  conditions  last  only  a  few  hours ;  the  contents  of  the 
hallucinations  are  frightful  in  character  and  consciousness 
is  in  a  dreamy  state.  Acts  of  violence  may  be  committed 
while  only  a  summary  memory  remains.  In  old  topers 
such  a  condition  may  also  be  superadded  to  the  permanent 
alcoholism.  But  when  an  apparently  healthy  individual 
falls  into  this  pathological  drunkenness,  these  severe  results 


336  HANDBOOK   OF   INSANITY. 

of  a  single  poisoning  with  alcohol  can  only  be  explained  on 
the  hypothesis  that  his  central  nervous  system  is  below  par. 
Sometimes  these  conditions  do  not  develop  until  some 
time  after  the  ingestion  of  alcohol,  especially  after  the 
passions  have  been  aroused.  From  a  medico-legal  stand- 
point it  is  imj)ortant  to  remember  that  this  pathological 
drunkenness  is  always  associated  with  unconsciousness 
and  is  usually  followed  by  loss  of  memory  of  the  events 
which  happened  during  it. 

Chronic  alcoholism  embraces  all  those  mental  and 
physical  disturbances  of  function  which  are  produced  by 
the  habitual  abuse  of  alcohol.  Drunkenness  is  always  as- 
sociated, however,  with  other  causes,  and  is  indeed  often 
the  result  of  such  causes,  viz.,  family  cares,  worry,  etc.; 
or  the  love  of  drink  may  be  merely  a  part  symptom  of  an 
underlying  general  morbid  predisposition.  The  abuse  of 
alcohol  also  acts  by  giving  rise  to  purely  physical  disorders, 
particularly  to  diseases  of  the  digestive  organs  and  to 
changes  in  the  vascular  apparatus. 

The  main  element  in  the  psychical  changes  is  the  pro- 
gressive loss  of  ethical  and  intellectual  functions,  the 
former  being  usually  first  affected.  The  notions  which 
are  based  on  customs  and  morals,  and  which,  in  connec- 
tion with  the  personal  elements  of  the  temperament,  im- 
part to  the  latter  its  special  coloring — in  a  word,  the 
character  of  the  patient  gradually  changes  and  finally  is 
lost.  He  loses  the  capacity  of  acting  according  to  prin- 
ciple. His  views  concerning  honor  and  propriety  become 
lax,  and  all  the  higher  feelings  yield  to  the  impulses  of 
the  moment.  Egoism  becomes  the  mainspring  of  all 
actions,  and  finally  everything  is  sacrificed  to  the  desire 
for  drink,  which  alone  is  capable  of  relieving  temporarily 
the  distressing  results  of  the  alcoholic  poisoning.  At  the 
beginning  there  may  be  a  severe  struggle  between  the 
growing  passion  and  the  patient's  self-control,  but  usually 
the  latter  succumbs.  The  habitual  drunkard  finally  be- 
comes a  confirmed  liar,  upon  whose  statements  not  the 
slightest  reliance  may  be  placed.     The  moral  degeneration 


CHRONIC   ALCOHOLISM.  337 

progresses  until  nothing  will  prevent  the  individual  from 
committing  even  deeds  of  violence  in  order  to  obtain  drink. 

This  loss  of  character  becomes  evident  long  before  the 
apppearance  of  intellectual  weakness.  For  this  reason 
the  individual  is  handled  with  difficulty,  inasmuch  as  the 
intact  intelligence  makes  [it  appear  improbable  to  the  ma- 
jority that  his  offences  against  law  and  morals  are  due  to 
a  pathological  mental  disturbance.  It  cannot  be  denied 
that  at  this  stage  the  patients  are  not  proper  subjects  for 
asylum  treatment,  because  the  necessity  of  removing  all 
opportunities  for  obtaining  drink  compels  us  to  place 
them  in  wards  in  which  their  personal  liberty  is  greatly 
curtailed.  In  such  wards  they  cannot  be  kept  long  be- 
cause they  are  unavoidably  brought  in  contact  with  many 
sad  experiences.  The  patients  should  be  placed  in  inebri- 
ate asylums,  because  experience  has  shown  that  abstinence 
from  alcohol  for  one  to  two  years  occasionally  permits  the 
redevelopment  of  an  intact,  morally  vigorous  emotional 
life,  and  often  warrants  a  return  to  former  pursuits.  When 
this  does  not  take  place  the  inebriate  asylum  will  pre- 
vent further  degeneration. 

The  docility  of  patients  who  are  deprived  of  alcohol  is 
sometimes  surprising.  The  fact  that  this  is  most  marked 
at  the  beginning  of  such  treatment  proves  that  it  is  due 
to  a  morbid  condition  of  exhaustion.  In  general,  the 
nervous  system  becomes  impaired  under  the  prolonged 
abuse  of  alcohol,  and  hence  so  many  neurasthenics  are 
found  among  drunkards.  Their  irritability  is  often  ex- 
treme, and  the  slightest  provocation  may  give  rise  to 
violent  passion  and  outbursts  of  rage,  in  which  all  con- 
sideration for  those  about  them  is  lost.  Sometimes  the 
sudden  anger  is  vented  upon  their  own  person.  Profound 
depression  is  apt  to  occur,  especially  in  the  morning, 
sometimes  with  a  tendency  to  suicide,  but  after  renewed 
ingestion  of  alcohol  this  mood  disappears  and  may  change 
to  the  opposite.  This  frequent  change  corresponds  to 
their  indecision  in  acting  and  to  their  weakness  of  will 
power. 

22 


338  HANDBOOK   OF   INSANITY. 

Even  at  this  stage  the  intelligence  often  remains  intact. 
Occasionally  impairment  of  memory  first  develops,  then 
there  is  rapid  loss  of  the  power  of  attention,  especially  in 
independent  mental  activity.  The  patient  may  take  in- 
telligent interest  in  a  conversation,  but  can  no  longer  read 
a  book  attentively  or  do  scientific  work.  But  in  every 
case  the  impairment  of  intelligence  is  recognizable  in  the 
one-sided  and  insufficient  comprehension  and  interpreta- 
tion of  new  impressions,  so  that  thought  is  confined  to  the 
patient's  own  immediate  interests.  In  this  way  there  is 
a  gradual  decay  of  mental  life  which  may  progress,  often 
after  the  lapse  of  many  years,  to  complete  dementia. 
This  is  hastened  by  the  development  of  other  psychoses  or 
severe  symptoms  in  other  parts  of  the  nervous  system. 

Two  factors  characterize  alcoholism  when  the  symptoms 
just  described  are  complicated  by  temporary  or  permanent 
psychical  disorders,  viz.,  the  character  and  great  number 
of  the  hallucinations  and  the  frequency  of  the  delusion 
of  marital  infidelity. 

The  hallucinations  are  extremely  mobile  and  variable, 
often  of  a  very  fantastic  character.  In  great  part  they 
may  be  mere  illusions,  due  to  the  imperfect  interpretation 
of  actual  occurrences.  Lights  and  movable  objects  play 
a  great  part  in  this  process.  A  feature  common  to  all 
these  hallucinations  is  their  elementary  and  fantastic 
character.  Lights,  flames,  and  stars  alternate  with  clouds ; 
a  spot  forms  before  the  eye,  assumes  regular  outlines, 
a  head  or  claws  appear,  and  gradually  is  converted  into 
an  animal;  this  changes  its  position,  disappears,  then 
returns  to  its  former  position.  All  possible  and  impossible 
animals  may  appear,  but  small  ones  predominate.  They 
run  around  the  room,  jump  upon  the  patient,  grow,  dis- 
appear in  the  floor  or  wall.  He  sees  fire,  combats,  battles 
hordes  advance  upon  him.  These  appearances  are  gener- 
ally of  a  frightful,  rarely  of  a  pleasant  character.  In  the 
latter  event  birds,  brilliant  flowers,  and  beautful  land- 
scapes are  seen.  The  auditory  hallucinations  are  like- 
wise of  an  elementary  character,  such  as  roaring,  tinkling, 


ACUTE   ALCOHOLIC    INSANITY.  339 

hissing,  shooting.  When  they  assume  a  definite  shape 
their  contents  are  usually  threatening,  mocking,  insulting. 
The  large  number  of  sounds  is  also  characteristic.  The 
same  features  are  found  in  the  rarer  cases  in  which  smell 
and  taste  are  affected,  and  hence  we  can  understand  the 
peculiar  symptoms  presented  by  the  alcoholic  delusion  of 
persecution.  To  make  the  description  complete,  a  few 
farther  details  are  requisite.  Hallucinations  of  feeling 
occur  in  a  similar  way ;  the  patients  feel  animals  entering 
the  skin  and  gnawing  their  limbs;  the  fire  burns  their 
hair  and  skin.  Such  changes  of  feeling  sometimes  de- 
velop in  the  sexual  apparatus,  and  are  then  apt  to  be  asso- 
ciated with  the  delusion  of  marital  infidelity  and  un- 
founded jealousy.  In  fact,  sexual  life  is  very  commonly 
drawn  into  the  morbid  symptoms,  so  that  the  delusion  of 
jealousy  is  sometimes  regarded  as  peculiar  to  alcoholism. 
In  some  cases  it  may  be  due  to  increased  desire  asso- 
ciated with  rapidly  progressing  impotence,  as  occurs  es- 
pecially in  advanced  cases  of  alcoholism.  The  delusion 
of  jealousy  is  not  always  founded  on  hallucinations,  but 
irrelevant  words  and  gestures  are  interpreted  in  the  sense 
of  the  delusion.  Sometimes  the  patients  (male  and  female) 
accuse  those  around  them  of  making  improper  proposals. 

So-called  acute  alcoholic  insanity  generally  begins  at 
night,  quite  suddenly,  and  may  disappear  within  a  few 
days.  This  condition  is  distinguished  from  the  closely 
allied  delirium  tremens  by  the  predominance  of  sexual 
ideas,  which  are  combined  into  a  confused  system  with 
the  other  symptoms,  consciousness  remaining  compara- 
tively clear ;  olfactory  hallucinations  are  quite  frequent ; 
the  motor  disorders  which  are  prominent  in  delirium 
tremens  are  not  pronounced. 

A  few  words  with  regard  to  the  motor  and  sensory  dis- 
orders of  chronic  alcoholism  in  its  ordinary  form.  Tremor 
of  the  tongue,  facial  muscles,  and  hands  is  commonly 
present,  and  is  more  distinct  in  the  sober  condition  than 
during  the  immediate  effect  of  alcohol.  Localized  cramps, 
for  example,  in  the  calves,  are  rarer.     Distinct  paralyses 


340  HANDBOOK   OF   INSANITY. 

are  not  very  common ;  pareses  are  more  frequent.  These 
symptoms  are  often  due  to  peripheral  neuritis.  Circum- 
scribed ansesthesias  or  pains  in  the  limbs  may  be  very 
annoying  and  may  form  the  basis  of  delusions.  Visual  im- 
pairment may  result  from  retinitis  and  temporary  changes 
in  sight  to  circulatory  changes.  Vaso-motor  paralyses  of 
various  kinds  occur  in  alcoholism ;  for  example,  enlarge- 
ment of  the  vessels  in  the  face,  degeneration  of  the  walls 
of  the  vessels  and  the  heart.  Affections  of  the  digestive 
tract  also  influence  the  patient's  mood. 

Before  discussing  the  course  and  termination  of  chronic 
alcoholism,  we  must  examine  the  peculiar  condition  known 
as  delirium  tremens.  It  rarely  follows  a  single  excess 
and  never  follows  a  single  intoxication  in  an  otherwise 
temperate  individual.  It  occurs  usually  after  some  excit- 
ing cause,  such  as  an  injury  or  a  pneumonia,  but  may  also 
develop  independently  during  the  course  of  alcoholism. 
Hard  drinkers  of  whiskey  rarely  escape  it,  although  its" 
frequency  depends  upon  other  external  circumstances, 
especially  upon  the  general  nutrition.  It  is  rare  when  the 
alcoholism  is  produced  by  good  wines  and  beer.  It  is  un- 
necessary to  enter  again  in  detail  into  the  symptoms 
which  are  common  to  delirium  tremens  and  to  alcoholic 
insanity.  The  contents  of  the  hallucinations  are  approxi- 
mately the  same  in  both  conditions.  The  visual  hallucina- 
tions generally  have  the  characteristic  of  small  size  and 
are  also  extremely  numerous.  It  is  very  probable  that 
the  appearance  of  animals  in  such  large  numbers  is  due 
to  disorders  of  accommodation  and  to  changes  in  the  fun- 
dus oculi,  i.  e. ,  their  development  is  in  great  part  peripheral. 
They  are  terrifying  to  the  patient,  especially  as  they  are 
associated  with  corresponding  hallucinations  of  hearing 
and  the  tactile  sense.  Among  the  latter  the  feeling  of 
crabs,  snakes,  spiders,  and  ants  upon  and  in  the  skin  is 
especially  characteristic,  and  upon  them  depends,  in  part, 
the  constant  picking  at  the  bedclothes  which  is  almost 
always  observed  at  the  height  of  the  disease. 

During  these  hallucinations  consciousness  is  profoundly 


DELIRIUM   TREMENS.  341 

impaired,  but  not  entirely  lost,  because  the  patients  will 
answer  questions  for  a  moment  when  addressed  in  a  per- 
emptory tone.  Insomnia  is  prominent  among  the  pro- 
dromes, likewise  a  great  susceptibility  to  fright,  and 
these  symptoms  are  always  present  in  the  fully  developed 
disease.  As  consciousness  is  not  entirely  lost  and  atten- 
tion can  be  aroused  momentarily,  the  conduct  of  the 
patient  often  appears  awkward  and  foolish.  This  impres- 
sion is  strengthened  by  the  mobile  restlessness  of  the 
patients  and  the  manner  in  which  they  are  constantly  oc- 
cupied with  the  objects  of  their  hallucination.  The  grab- 
bing for  the  rapidly-moving  apparitions  and  the  conversa- 
tion with  the  innumerable  beings  that  storm  upon  him 
often  converts  the  scene  into  a  lively  spectacle  which 
may  exhibit  even  comic  effects.  In  other  cases  great 
anxiety  predominates,  but  a  delusion  of  persecution  is 
usually  not  expressed  in  set  terms.  The  inimical  con- 
tents of  the  hallucinations  may  give  rise,  however,  to  acts 
of  violence  against  the  patient's  own  life  or  against  those 
around  him.  Even  apart  from  definite  hallucinations, 
the  consciousness  is  filled  by  terrifying  thoughts,  as  is 
evident  from  the  fact  that  patients  suffering  from  delir- 
ium tremens  and  chronic  alcoholism  very  often  assert 
that  they  or  others  in  their  company  have  committed  a 
murder. 

The  hallucinations  are  usually  most  marked  as  soon  as 
the  patient  closes  his  eyes  in  order  to  fall  asleep,  probably 
on  account  of  the  pressure  on  the  eyeball.  In  the  same 
way  a  convalescent,  by  closing  the  eyes,  may  reproduce 
visual  hallucinations  which  had  disappeared. 

The  motor  disorders  of  delirium  tremens  are  of  great 
importance.  Apart  from  the  constant  motion  due  to  the 
hallucinations,  there  is  also  direct  muscular  restlessness. 
This  is  shown  by  purposeless  walking  and  by  the  push- 
ing away  of  objects  which  happen  to  be  in  the  way. 
Bathed  in  perspiration  and  completely  exhausted,  the 
patient  may  break  down,  or  after  a  few  moments  of  ex- 
haustion   and   apparent    quiet    the   scene   begins  anew. 


342  HANDBOOK   OF   INSANITY. 

Motor  disorders  due  to  direct  central  irritation  also  ap- 
pear in  the  form  of  rapid  twitchings  of  the  facial  muscles, 
especially  around  the  mouth  and  eyes,  and  in  the  shape  of 
nystagmus;  in  the  form  of  tremor  they  extend  to  the 
trunk  and  limbs.  Tremor  is  most  distinct  in  the  ex- 
tended fingers  and  the  protruded  tongue.  Speech  is  thick 
and  difficult,  chiefly  from  loss  of  power.  This  is  also 
shown  in  the  uncertain  and  tottering  gait,  but  in  mo- 
ments of  excitement  and  rage  this  is  lost  and  the  patient's 
strength  may  be  almost  incredible.  General  epileptic 
convulsions  are  not  very  infrequent. 

As  the  reflex  irritability  is  very  much  increased,  the 
limbs  are  tossed  about  in  bed  and  slight  injuries  are  often 
produced  in  this  way.  Even  severe  injuries,  such  as  frac- 
tures, may  be  unnoticed  on  account  of  the  impairment  of 
consciousness  and  perhaps  diminished  sensibility  to  pain. 
Uncomplicated  delirium  tremens  is  usually  apyrexial, 
but  in  the  severest  forms  there  may  be  an  extreme  rise  of 
temperature.  In  such  cases  death  is  the  usual  termina- 
tion. In  others  death  may  occur  from  general  exhaustion, 
without  fever;  the  pulse  becomes  soft  and  small,  an  ir- 
regularly flickering  delirium  ends  in  complete  loss  of  con- 
sciousness, feeble  movements  are  still  indicated,  the 
twitchings  become  subsultus,  and  the  vital  energies  are 
extinct.  The  average  mortality  is  about  twenty  per  cent, 
death  being  due  to  exhaustion,  pneumonia,  severe  in- 
juries, suicide,  and  accidental  complications.  Cases  that 
recover  usually  run  their  course  in  three  to  eight  days. 
Sometimes  a  short  sleep  seems  to  indicate  recovery, but  this 
may  be  delayed,  sometimes  for  several  weeks,  by  a  fresh 
exacerbation  of  the  excitement.  In  mild  cases  a  profound 
and  prolonged  sleep  checks  the  delirium  so  completely  that 
the  patient  awakes  entirely  well. 

The  relief  of  the  insomnia  constitutes  the  most  important 
element  of  treatment.  At  the  onset  hypnotics  are  gener- 
ally useless,  but  they  become  very  effective  toward  the  close 
of  the  attack.  Chloral  hydrate  is  the  preferable  remedy 
unless  contra-indicated  by  cardiac  disease.     Otherwise  the 


CHRONIC   ALCOHOLISM.  343 

treatment  is  restricted  to  careful  feeding  and  to  measures 
necessary  to  protect  the  patient  and  those  about  him  from 
injury.  Everything  with  which  the  patient  might  injure 
himself  or  others  should  be  removed.  Personal  restraint 
by  straight- jackets,  etc.,  should  not  be  permitted  because 
pneumonia  and  oedema  of  the  lung  are  apt  to  develop.  In 
addition  to  nourishing  food,  especially  milk,  moderate 
amounts  of  alcoholics  should  be  given.  This  should  also 
be  done  in  all  cases  of  alcoholism  which  come  under 
treatment  for  some  other,  especially  febrile,  disease  or  on 
account  of  an  injury.  Under  such  circumstances  the  sud- 
den abstinence  from  alcohol  may  give  rise  to  an  attack 
of  delirium  tremens. 

After  an  attack  of  delirium  tremens  the  tremor  of  the 
limbs,  especially  of  the  hands,  may  last  for  a  long  time. 

We  find  the  condition  returns  to  its  former  status,  and 
we  thus  return  to  the  point  in  the  further  course  of 
chronic  alcoholism  which  we  reached  a  little  while  ago. 
If  this  course  is  not  interrupted  by  the  conditions  of  ex- 
citement already  described,  it  is  tolerably  uniform  in  its 
progress.  But  there  is  one  form  of  mental  disorder  which 
may  occur  in  a  chronic  drinker  after  a  single  excessive 
intoxication  or  several  rapidly  following  excesses.  True 
alcoholic  poisoning  is  then  combined  with  the  already 
existing  general  change.  The  clinical  history  then  pro- 
duced contains  the  majority  of  the  other  symptoms  pressed 
close  together  and  developed  to  a  high  degree.  Hence 
there  is  a  great  similarity  to  galloping  dementia  para- 
lytica. The  mood  is  very  exalted,  immoderate  ideas  of 
grandeur  develop,  associated  with  great  loquacity  and 
muscular  restlessness,  and  pupillary  differences,  facial 
paralyses,  general  tremor,  and  great  difficulty  of  speech 
complete  the  deceptive  impression  of  dementia  paralytica. 
But  this  alcoholic  paresis  does  not  usually  advance  to  de- 
mentia ;  within  a  few  weeks  or  months  it  disappears  and 
the  patient  recognizes  his  condition.  Recovery  is  perma- 
nent in  so  far  as  it  is  not  affected  by  the  other  symptoms 
of   chronic  alcoholism.     This   condition   must  be  distin- 


344  HANDBOOK   OF   INSANITY. 

guished  from  the  dementia  with  paralyses  which  may- 
develop  in  a  remarkably  slow  manner  during  the  course 
of  ordinary  chronic  alcoholism.  In  the  former  condition 
epileptiform  paralytic  attacks  are  rare,  while  the  combi- 
nation of  alcoholism  with  epilepsy  is  especially  apt  to 
provoke  the  slow  process  into  dementia.  As  a  matter  of 
course,  the  alcoholic  patient  may  also  be  attacked  by  true 
paralytic  dementia,  but  the  latter  differs  in  its  clinical 
course  from  dementia  with  paralyses.  Apart  from  the 
lesser  intensity  of  all  the  symptoms,  it  lacks  the  progres- 
sive course,  and  if  gradual  and  complete  abstinence  from 
drink  is  secured  we  can  effect  a  standstill  and  consider- 
able improvement.  Indeed,  chronic  poisoning  with  alco- 
hol rarely  leads  to  the  highest  grades  of  dementia. 

A  few  words  must  be  devoted  to  so-called  alcoholic 
epilepsy.  Intense  alcoholic  poisoning  in  a  chronic  hard 
drinker,  as  well  as  in  a  moderate  drinker,  may  give  rise 
to  a  condition  of  profound  disturbance  of  consciousness, 
which  lasts  long  after  the  drunken  fit,  is  associated  with 
epileptic  convulsions,  and,  on  account  of  the  development 
of  hallucinations,  may  closely  resemble  certain  epileptic 
states  and  equivalents.  The  resemblance  is  increased  still 
farther  by  the  very  rapid  course  of  the  symptoms,  their 
rapid  cessation,  and  the  loss  of  memory  for  events  occurring 
during  this  state.  Individuals  are  attacked  who  were  not 
previously  epileptic,  although  epileptics  who  have  become 
addicted  to  alcohol  may  also  exhibit  similar  conditions. 
If  this  condition  develops  only  once,  it  may  be  called  a 
pathological  drunkenness  in  the  sense  already  described. 
These  convulsive  seizures  are  apt  to  return  after  every 
severe  intoxication,  and  to  such  cases  the  term  alcoholic 
epilepsy  is  best  suited. 

After  the  ingestion  of  enormous  amounts  of  poor  alcohol, 
the  highest  degree  of  intoxication  may  be  manifested 
from  the  start  in  complete  unconsciousness  and  paralysis, 
and  this  often  terminates  fatally  in  a  short  period  from 
acute  oedema  of  the  brain. 

As  a  general  thing  chronic  alcoholics  die,  before  they 


ANATOMICAL   CHANGES.  345 

have  reached  the  hightest  grades  of  mental  and  physical 
decay,  from  some  intercurrent  organic  affection.  The 
character  of  the  alcoholic  drink  is  of  great  importance  as 
regards  the  rapidity  of  the  entire  condition. 

Alcoholic  stimulants  that  contain  fusel  oil  are  much 
more  dangerous  than  others ;  the  brain  then  suffers  from 
the  action  of  the  adulterations.  For  this  reason  alcohol- 
ism is  so  wide-spread  among  the  lower  classes.  It  is  much 
less  frequent  among  drinkers  of  beer  and  wine. 

The  constant  drinking  of  smaller  amounts  of  alcoholic 
stimulants  is  usually  much  more  dangerous  than  periodi- 
cal excesses.  Dipsomania  {vide  page  96)  is  not  one  of  the 
causes  of  chronic  alcoholism,  but  when  this  condition  coex- 
ists in  a  case  of  chronic  alcoholism  it  constitutes  an  im- 
portant factor,  and  such  patients  usually  fail  very  rapidly. 

When  simple  psychoses  develop  upon  an  alcoholic  basis, 
we  must  distinguish  between  the  temporary  effect  of 
alcoholism  and  an  independent  psychical  affection  in  an 
habitual  drinker.  In  the  former  event,  severe  symptoms 
are  especially  manifest  at  the  start  and  the  disease  also 
runs  a  severe  course.  Alcoholism  may  not  be  inferred, 
however,  from  the  slight  power  of  resistance  to  small 
amounts  of  alcohol,  because  such  intolerance  occurs  in 
many  nervous  systems  which  are  below  par.  It  is  doubt- 
ful whether  the  psychoses  of  habitual  drunkards  which 
are  due  to  some  other  exciting  cause  exhibit  any  specific 
symptoms. 

Apart  from  the  numerous  changes  in  other  organs,  an- 
atomical changes  develop  in  the  brain  and  meninges  after 
alcoholism  has  continued  for  a  long  time.  Inflammations 
and  thickening  of  the  meninges,  atrophy  of  the  brain  sub- 
stance, especially  of  the  cortex,  and  internal  hydrocephalus 
then  become  prominent.  But  the  motor  disorders,  espe- 
cially paralyses,  often  result  from  diseases  of  the  spinal 
cord  and  its  membranes  and  from  inflammations  of  the 
peripheral  nerves. 

As  the  treatment  of  the  psychoses  which  are  associated 
with  alcoholism  is  based  on  general  principles,  it  only  re- 


346  HANDBOOK   OF   INSANITY. 

mains  for  us  to  make  a  few  remarks  on  the  treatment  of 
alcoholism.  Complete  restoration  cannot  be  expected,  and 
we  must  be  satisfied  with  an  amelioration  of  the  symptoms. 
We  may  repeat  that  most  can  be  done  by  diminishing  the 
quantity  and  improving  the  quality  of  the  noxious  poison. 
There  are  no  positive  remedies  or  curative  methods.  Per- 
manent abstinence  from  alcohol  prevents  farther  progress, 
but  very  few  will  decide  upon  permanent  seclusion  from 
the  world  if  a  tolerable  equilibrium  is  obtained  after  the 
disappearance  of  the  most  severe  symptoms. 

J.    FEEBLE-MINDEDNESS    (IMBECILITY   AND    IDIOCY). 

The  artificial  character  of  our  classification  is  again 
shown  very  clearly  in  this  section.  The  extreme  grades  of 
idiocy  under  the  form  of  cretinism  apparently  have  nothing 
in  common  with  the  milder  forms  of  feeble-mindedness, 
especially  if  they  are  not  congenital  but  remain  after  a  psy- 
chosis. These  different  groups  are  arranged  in  one  class 
because  they  belong  together  clinically.  The  antitheses 
at  both  ends  of  the  series  are  joined  to  one  another  by 
numerous  transitions  whose  -  essential  clinical  feature  is 
mental  weakness.  The  milder  conditions  of  mental  weak- 
ness which  result  from  other  psychoses  must  be  considered 
separately  from  profound  dementia,  and,  in  view  of  their 
clinical  relationship,  in  conjunction  with  congenital  fee- 
ble-mindedness or  imbecility.  Clinically,  the  latter  ap- 
proaches the  mild  grades  of  idiocy  in  which  there  are 
only  slight  anatomical  changes.  Then  a  slight  step  leads 
clinically  and  anatomically  to  the  higher  and  highest 
grades  of  idiocy  and  cretinism.  These  are  distinguished 
from  the  acquired  forms  of  dementia  by  the  congenital 
anatomical  changes. 

Concerning  the  first  group  of  acquired  feeble-minded- 
ness little  need  be  said  (although  it  is  one  of  the  most  ex- 
tensive classes),  because  it  is  a  termination  of  many 
functional  simple  psychoses.  One  of  its  most  strik- 
ing features   is  diminished  endurance   in  mental  work,, 


IMBECILITY.  34? 

while  the  individual  ability  in  the  customary  occupation 
may  still  be  sufficient.  Indications  of  the  antecedent 
psychosis  are  wanting,  while  the  mental  decay  which 
passes  into  dementia  still  contains  such  elements  and  thus 
shows  that  the  morbid  process  is  extending  more  deeply. 
In  the  feeble-mindedness  to  which  we  refer  this  has 
ceased  and  the  condition  has  become  a  permanent  sequel. 
Unlike  neurasthenia,  the  ready  exhaustion  is  confined  to 
mental  activities,  while  other  nervous  functions  are  not 
enfeebled.  But  the  higher  psychical  functions,  especially 
in  the  ethical  field,  are  also  impaired,  and  defects  in  moral 
views  are  noticeable  when  actions  are  required  which  call 
for  independent  decision. 

In  congenital  feeble-mindedness  or  imbecility  the  con- 
dition differs  merely  in  its  mode  of  development,  not  in 
its  clinical  aspects.  Here  there  has  never  been  a  thorough 
comprehension  of  the  depth  of  moral  convictions,  and  the 
discrepancy  between  morals  and  the  acts  of  an  imbecile 
depends  essentially  upon  his  lack  of  judgment,  which  is 
often  manifested,  particularly  in  this  connection.  Very 
often  imbeciles  exhibit  excellent  mental  attainments  in 
other  circumscribed  fields.  In  matters  which  depend 
chiefly  on  memory  they  often  develop  great  cunning. 
Otherwise  the  observation  and  comprehension  of  the  outer 
world  are  confined  to  objects  under  their  immediate 
notice  and  to  the  conditions  and  interests  of  their  own 
person.  If  their  wants  are  satisfied  they  may  lead  quiet, 
harmless  lives ;  if  not,  we  may  be  surprised  by  outbursts 
of  anger  and  violence  which  show  that  self-control  is  en- 
tirely wanting.  No  sorrow  or  remorse  is  felt  after  the 
period  of  excitement  has  passed.  The  directness  with 
which  their  resolutions  spring  from  the  internal  conditions 
of  the  body  shows  the  close  relationship  to  the  impulsive 
acts  of  idiots. 

From  a  causal  standpoint  feeble-mindedness  which  re- 
sults from  brain  disease,  injury  to  the  skull  or  concussion 
in  early  childhood,  stands  midway  between  congenital 
imbecility  and  the  conditions  of  mental  weakness  following 


348  'HANDBOOK   OP   INSANITY. 

a  psychosis  in  mature  years.  Clinically  these  cases  show- 
no  material  difference.  But  if  an  imbecile  is  attacked  by 
a  psychosis  in  later  life,  the  course  of  the  disease  exhibits 
distinct  peculiarities.  Awkward  and  childish  conduct  be- 
comes prominent.  The  morbid  manifestations  of  the 
changed  mood  far  exceed  the  usual  mean.  The  expression 
of  exalted  self-esteem  or  of  timid  self -depreciation  can  no 
longer  be  measured  by  the  possible.  Delusions  of  grandeur 
occur  in  degrees  which  are  otherwise  found  only  in  para- 
lytic dementia.  The  disease  presents  unforeseen  and  sur- 
prising changes.  Many  incomprehensible  features  in  a 
psychical  disorder  which  develops  upon  a  basis  of  feeble- 
mindedness can  only  be  explained  by  this  basis.  These 
patients  furnish  numerous  instances  of  conflicts  with  the 
law  and  public  morals. 

The  backwardness  as  regards  the  higher  psychical  feel- 
ings may  be  more  distinct  than  the  imperfect  development 
of  the  intellect.  The  term  moral  insanity  is  often  used 
wrongly  for  such  conditions.  The  moral  defect  never  ex- 
ists without  implication  of  the  other  mental  faculties,  and 
the  former  merely  predominates. 

The  impossibility  of  acquiring  the  higher  moral  ideas  as 
a  living  reality  entails  the  inability  of  understanding  their 
worth  in  general.  These  individuals  confine  all  their  feel- 
ings and  endeavors  upon  themselves  and  their  own  advan- 
tage. The  mentally  normal  individual  in  modern  society 
must  always  be  able  to  comprehend  the  reasons  which 
prevent  him  from  recklessly  satisfying  his  immediate 
selfish  desires.  This  ability  is  lacking  in  the  feeble- 
minded individual,  although  he  grows  up  in  the  midst  of 
civilization,  from  whose  blessings  he  constantly  draws  an 
abundant  supply.  The  laws  of  morals  may  be  studied  and 
memorized,  but  they  remain  dead  masses  of  ideas. 

The  absence  of  sympathy  is  shown  at  an  early  age  by 
the  tendency  to  torture  animals  or  to  enjoy  their  sufferings. 
Indifference  is  manifested  toward  the  nearest  relatives, 
even  toward  the  parents.  In  some  cases  such  phenomena 
appear  with  more  or  less  distinctness  at  certain  intervals, 


SYMPTOMS   IN  YOUTH.  3491 

and  we  may  here  remind  the  reader  of  our  former  remarks 
on  periodical  psychoses.  In  childhood  these  individuals 
are  lazy  and  lying,  the  despair  of  their  parents  and  teach- 
ers; in  youth  they  become  vagabonds,  commit  theft; 
among  them  we  find  congenital  criminals,  especially 
thieves.  They  soon  become  the  plague  of  the  authorities, 
are  not  amenable  to  punishment,  and  regard  the  laws 
merely  as  police  regulations  whose  results  they  must  avoid. 
Finally,  they  gratify  their  propensities  impulsively,  with- 
out regard  to  consequences.  There  is  an  uncontrollable 
desire  to  masturbate  and  to  gratify  their  sexual  impulses, 
even  in  early  youth. 

Immorality  and  coarseness,  cruelty  and  malice,  may 
appear  so  much  more  deserving  of  punishment  because  they 
are  associated  not  infrequently  with  a  certain  degree  of  dia- 
lectic skill.  Delusions  and  hallucinations  are  absent.  It 
is  then  difficult  to  demonstrate  intellectual  defects,  although 
one  circumstance  aids  us  in  disclosing  the  inhibition  of 
the  development  of  mental  life.  In  school  these  individ- 
uals may  be  the  equals  of  their  companions  up  to  a  certain 
period,  but  a  striking  feature  is  their  unequal  power  of 
attention.  Then,  almost  suddenly,  they  remain  backward, 
often  at  the  period  of  puberty,  and  cannot  keep  pace  with 
their  comrades  when  independent  thought  is  required. 
It  seems  as  if  the  internal  development  of  the  brain  sud- 
denly ceases.  This  defect  becomes  more  evident  in  the 
choice  of  a  life  career.  They  are  unpractical  individuals. 
If  the  other  members  of  the  family  are  normal,  the  nature 
of  the  feeble-mindedness  becomes  more  distinct  from  the 
contrast.  If  the  hereditary  taint  is  pronounced,  the  mor- 
bid condition  becomes  so  much  clearer  to  the  physician ; 
but  the  internal  contradictions  must  be  shown  so  much 
more  carefully  to  the  legal  authorities.  Despite  their  ap- 
parent cunning,  the  acts  of  imbeciles  often  disregard  the 
ordinary  rules  of  prudence.  The  chief  object  is  always 
the  satisfaction  of  the  moment;  whether  this  is  propor- 
tionate to  the  means  employed  is  immaterial.  A  theft  is 
committed  in  order  to  spend  the  proceeds  in  ridiculously 


350  HANDBOOK   OF   INSANITY. 

useless  articles.  They  employ  intrigue  and  swindling 
methods  to  achieve  ends  which  could  be  obtained  much 
more  easily  by  honorable  methods.  There  is  no  reflection 
interposed  between  the  desire  and  the  deed,  but  its  execu- 
tion is  effected  by  impulse.  A  criminal  deed  is  some- 
times due  to  the  impulse  of  imitation. 

The  mental  ability  fails  still  farther  when  a  simple  con- 
ception suffices  to  convert  another  associated  concept  into 
an  actual  deed.  But  such  an  imperative  act  differs  essen- 
tially from  that  performed  by  a  neurasthenic.  The  latter 
straggles  continually  against  the  idea  which  is  constantly 
cropping  out  and  demanding  realization.  The  imbecile  is 
left  to  the  play  of  his  ideas,  without  reflection  or  internal 
struggle.  It  is  true  that  these  processes  are  associated 
with  vague  feelings,  but  the  imbecile  does  not  comprehend 
their  connection  with  his  notions  and  acts.  Many  acts 
appear  to  be  explained  in  this  way,  but  the  psychological 
explanation  is  often  found  rather  in  the  mind  of  the  ob- 
server than  of  the  patient.  For  example,  arson  committed 
by  imbeciles  may  only  be  explained  as  the  gratification  of 
revenge.  It  is  true  that  this  reason  actually  holds  good 
in  not  a  few  cases,  but  we  must  not  always  rely  upon  this 
when  the  young  incendiaries  declare  that  the  deed  was 
done  without  reason.  As  a  matter  of  fact,  the  thought  of 
fire  and  its  production  may  have  been  almost  simultaneous, 
or  the  childish  delight  in  flickering  flames  may  have  been 
sufficient  reason  for  starting  the  fire.  In  other  cases  home- 
sickness is  the  cause  of  arson  by  imbeciles,  because  they  im- 
agine that  they  can  then  change  their  abode.  Here,  again, 
the  reckless  choice  of  means  for  attaining  personal  ends 
permits  of  no  reflection  on  the  other  bearings  of  the  deed. 
The  impossibility  of  forming  higher  ethical  notions  en- 
ables us  to  recognize  the  intellectual  in  addition  to  the 
moral  weakness.  In  addition  to  the  inability  of  recogniz- 
ing vices  as  such,  f  eeble-mindedness  is  demonstrated  either 
by  the  slight  power  of  judgment  or  the  diminished  mental 
activity.  The  laziness  of  these  individuals  is  want  of  ca- 
pacity.     In  order  to   avoid  work  they  become  tramps, 


IMPERFECT  CEREBRAL  DEVELOPMENT.       351 

punishment  makes  them  still  more  obstinate,  and  the 
number  of  so-called  incorrigibles  in  prisons  includes  many- 
feeble-minded  individuals.  In  reformatories,  where  they 
are  properly  treated,  they  may  often  become,  in  a  measure, 
useful  individuals.  But  even  here  their  vanity,  which 
often  tells  them  that  they  accomplish  a  great  deal,  may  be 
a  great  obstacle  to  their  education  and  to  the  attempt  to 
make  them  amenable  to  the  regulations  of  the  institution. 

These  forms  of  imbecility,  whether  manifested  mainly 
in  the  moral  or  the  purely  intellectual  field,  do  not  show  a 
steady  advance  when  the  period  of  bodily  development 
has  passed.  We  have  already  seen,  however,  that  a  cer- 
tain periodical  course  of  the  symptoms  is  recognized  when 
there  is  an  hereditary  neurasthenic  basis.  Moreover,  ex- 
ternal accidental  factors,  such  as  an  injury  to  the  head  or 
a  severe  bodily  disease,  may  cause  a  long-continued  in- 
crease of  all  the  s3Tmptoms,  which  may  disappear  after  the 
removal  of  the  exciting  cause.  There  is  then  apparent 
recovery  if  the  original  feeble-mindedness  has  not  been 
marked  or  has  been  overlooked.  A  similar  condition  may 
be  observed  at  the  period  of  puberty.  Such  exacerbations 
of  an  originally  slight  imbecility  may  disappear  entirely, 
even  after  the  lapse  of  a  year. 

In  the  higher  grades  of  imbecility  the  accompanying 
anatomical  changes  can  no  longer  be  disregarded.  We 
must  then  employ  the  term  idiocy,  and  this  cannot  be 
separated  from  those  inhibitions  of  mental  development 
which  are  accompanied  by  distinct  anatomical  aberrations. 
We  have  to  deal  now  with  disorders  of  mental  and 
bodily  development  which  exist  from  birth  or  early  child- 
hood. The  individuals  in  question  remain  backward  and 
cannot  attain  the  culture  and  education  corresponding  to 
their  age  and  condition  in  life.  Deaf -mutism  will  not  be 
considered,  and,  in  fact,  those  developmental  disorders 
which  depend  on  sensory  deficiencies  (especially  blindness) 
are  not  really  the  objects  of  psychiatric  investigation. 

The  imperfect  development  of  the  brain,  upon  which 
idiocy  depends,  may  be  indicated  in  the  ovum  and  become 


352  HANDBOOK   OF   INSANITY. 

manifest  during  foetal  life,  but  the  disease  which  leads  to 
idiocy  usually  begins  after  birth,  during  the  first  five 
years  of  life.  Hence,  the  term  idiocy  includes  inhibitions 
of  development,  together  with  conditions  which  are  ac- 
quired in  early  life  as  the  result  of  morbid  changes  and 
destructions  of  important  parts  of  the  brain,  because  posi- 
tive signs  for  the  differentiation  of  these  modes  of  de- 
velopment are  wanting.  The  most  varied  anatomical 
changes  are  found  in  idiocy.  Thus,  the  brain  may  be  re- 
markably small  or  remarkably  large,  although  the  latter 
condition  is  rare.  The  structure  of  the  brain  may  then 
appear  to  be  well  developed  and  the  body  may  also  appear 
to  be  vigorous.  An  explanation  of  the  association  of  this 
condition  with  idiocy  is  impossible,  because  even  the  mi- 
croscope usually  shows  no  change. 

Much  more  frequent  and  important  is  the  small  size  of  the 
brain,  combined  with  that  of  the  skull.  The  latter  is  not 
always  the  cause  of  the  former,  because  premature  ossi- 
fication of  the  sutures  is  not  found  even  in  the  majority 
of  all  cases  of  microcephalus.  In  some  cases  certain,  but 
not  all,  children  of  the  same  mother,  who  belongs  to  a 
family  which  is  undoubtedly  free  of  hereditary  taint,  are 
microcephalic,  and  it  is  then  assumed  that  the  cause  is  an 
inhibition  of  the  growth  of  the  skull  and  brain  due  to 
mechanical  conditions,  for  example,  to  some  obstruction 
due  to  the  membranes,  but  not  to  the  uterus  itself,  be- 
cause in  the  latter  event  all  the  children  would  be  micro- 
cephalic. The  special  form  of  microcephaly  in  cretinism 
alone  appears  to  be  due  positively  to  premature  ossification, 
of  the  sutures  at  the  base  of  the  skull. 

For  the  present  we  will  consider  only  simple  microceph- 
alus, which  gives  rise  to  idiocy.  As  a  rule,  the  face  is 
well  developed,  but  the  jaws  are  sometimes  very  promi- 
nent ;  the  cranium  and  brain  are  extremely  small,  the  fore- 
head flat.  Although  the  convolutions  are  usually  simpli- 
fied, the  principal  fissures  generally  are  more  or  less  well 
developed ;  the  convolutions  are  very  rarely  entirely  nor- 
mal.    Other  changes  are  inequality  of  the  two  sides  of  the. 


CRETINISM.  353 

brain,  unusual  prominence  of  certain  fissures,  internal 
hydrocephalus,  and  porencephaly.  In  some  microcephalics 
the  brain  is  even  much  smaller  than  we  would  expect  from 
the  size  of  the  skull,  when  the  space  within  the  skull  is 
farther  restricted  by  hydrocephalus  or  pronounced  thick- 
ening of  the  bones. 

Partial  atrophy  of  the  brain  is  frequent,  but  the  clinical 
course  of  such  cases  is  not  materially  different  from  that 
observed  when  the  atrophy  is  general.  As  a  general  thing 
the  frontal  lobes  are  more  profoundly  affected,  but  in  other 
cases  the  occipital  lobes  are  chiefly  involved.  There  may 
also  be  small  sclerotic  foci  in  the  most  remote  parts  of 
the  brain  of  idiots.  A  difference  in  the  clinical  history 
develops,  however,  according  as  the  inhibition  of  develop- 
ment affects  the  cortex  at  the  convexit}r  or  those  parts  of 
the  brain  which  are  situated  at  the  base.  In  the  former 
event  the  idiocy  is  pronounced,  but  the  possibility  of  the 
free  development  of  the  brain  at  the  base,  where  the  motor 
tracts  are  found,  is  shown  by  the  fact  that  the  patients  are 
very  active  and  are  capable  of  co-ordinated  movements. 
When  the  base  of  the  skull  is  shortened  and  the  develop- 
ment of  the  basal  parts  is  inhibited,  the  patients  are  slow 
and  incapable  of  performing  delicate  movements.  This 
group  includes  cretins  proper. 

Cretinism  occupies  a  special  position  in  idiocy  because 
certain  bodily  symptoms  constantly  accompany  it  and  be- 
cause it  sometimes  appears  endemically.  Cretins  are  usu- 
ally dwarfs.  Although  the  head  is  diminished  in  size,  it 
is  relatively  large,  because  the  trunk  is  small,  often  child- 
like in  appearance.  The  features  are  old  and  ugly,  at  the 
same  time  childish.  Thick  lips,  heavy  lids,  deep  eyes 
and  a  broad  nose,  thickened  integument  of  the  face  and 
great  enlargement  of  the  thyroid  gland  complete  the  pecul- 
iar picture.  As  an  endemic,  cretinism  is  always  accom- 
panied by  goitre  and  occurs  only  in  high  mountain  ranges 
and  their  spurs.  Thus,  it  is  found  in  the  deep  valleys  of 
the  Alps,  Pyrenees,  Cordilleras,  Himalayas,  and  the  high 
ranges  of  China ;  it  is  much  rarer  among  lower  mountain 
23 


354  HANDBOOK   OF   INSANITY. 

ranges.  Although  hereditary  influences  are  not  excluded, 
a  local,  perhaps  contagious,  infection  appears  to  be  neces- 
sary. This  view  is  strengthened,  for  example,  by  the  fact 
that  distinct  signs  of  the  morbid  condition  do  not  develop 
until  several  months  afterbirth  or  even  later,  and  that  the 
children  of  healthy  immigrants  may  also  be  attacked  by 
cretinism.  The  cranial  deformity  may  vary  greatly,  but 
the  most  prominent  feature  is  the  inhibited  development 
of  the  base  of  the  skull ;  the  cretins  are  correspondingly  in- 
dolent. The  proliferation  of  the  cartilaginous  elements, 
which  precedes  ossification  in  the  healthy,  does  not  take 
place  in  all  the  other  bones  in  cretins.  This  premature 
cessation  of  ossification  checks  longitudinal  growth.  Even 
simple  idiots  attain  full  growth  only  at  a  comparatively 
late  period.     Cretinism  is  rarely  sporadic. 

The  general  condition  of  cretins  differs  so  little  from 
that  of  other  idiots  that  the  same  clinical  description  will 
serve  for  both.  We  will  first  touch  upon  a  few  other 
factors  which  lead  to  the  development  of  idiocy  or  accom- 
pany it  as  permanent  bodily  disorders.  Injuries  to  the 
head,  inflammations  of  the  brain  and  meninges  in  infancy 
may  lead  to  a  stand -still  of  mental  development  at  its  earli- 
est stage,  and  may  also  be  manifested  by  many  bodily 
errors  of  development.  Such  signs  of  degeneration  may 
be  distinguished  with  difficulty  from  the  signs  of  bodily 
degeneration  which  begin  early  in  foetal  life  and  hence  also 
accompany  a  congenital  idiocy.  These  conditions  include 
various  deformities  of  the  skull,  squinting,  malposition 
and  absence  of  teeth;  keel-shaped,  narrow,  and  high  pal- 
ate ;  defects  in  the  palate  and  iris,  deformities  of  the  gen- 
italia, etc. 

An  essential  feature  in  the  clinical  history  of  idiots  of 
all  ages  is  the  absence  of  attention.  This  is  so  much  more 
marked  because  accompanying  feelings  upon  which  at- 
tention must  be  based  are  extremely  feeble.  Hence  very 
few  concepts  are  formed  from  the  sensory  impressions, 
and  the  former  are  so  superficial  that  they  rapidly  disap- 
pear.    The  semi-sensory  concepts  are  not  combined  with 


idiocy.  355 

others  into  a  real  mental  possession.  There  is  an  absence 
of  firmly  arranged  notions  which  decide  the  impulses  of 
the  will,  and  there  is  also  a  lack  of  comprehension  of  men- 
tal values  which  lead  outside  of  the  obscure  feelings  and 
impulses  of  the  patient's  own  ego.  The  lack  of  compre- 
hension becomes  more  distinct  the  more  the  development 
of  speech  is  inhibited,  because  the  possibility  of  education 
depends  materially  upon  speech.  Even  when  speech  has 
been  acquired  quite  completely,  its  use  is  ordinarily  con- 
fined to  a  few  phrases  and  sentences.  This  is  due  to  the 
lack  of  interest  in  surrounding  circumstances.  The  more 
strongly  the  attention  can  be  aroused,  at  least  for  a  time, 
the  more  perfect  does  speech  become  and  the  more  exten- 
sive are  the  relations  to  the  outer  world.  The  greater  the 
number  of  senses  brought  into  play  in  these  relations,  the 
better  are  the  chances  of  improvement.  Hence,  the  main 
principle  in  the  education  of  idiots  is  the  simultaneous 
stimulation  of  several  senses  (sight,  hearing,  feeling). 
This  also  explains  the  great  difficulty  in  the  education  of 
children  with  defective  senses. 

Even  when  an  idiot  has  acquired,  in  a  measure,  the  or- 
dinary branches  of  study,  the  contents  of  his  mental  life 
are  usually  confined  to  a  few  groups  of  ideas.  In  some  of 
these  cases  one-sided  talents  are  developed  in  an  unusual 
degree,  but  often  in  an  impulsive  and  semi-conscious 
manner,  in  which  a  mechanical  sort  of  memory  constitutes 
the  chief  element.  All  higher  endeavors  are  wanting,  and 
the  mental  processes  are  associated  only  with  personal 
sensations.  Joy  and  sorrow  are  based  chiefly  on  bodily 
conditions,  or  they  appear  to  be  due  directly  to  unknown 
changes  in  the  condition  of  the  brain.  These  emotional 
manifestations  are  found  in  the  lowest  forms  of  idiocy  and 
consist  of  two  kinds.  On  the  one  hand,  a  morose,  often 
brutal  and  terrifying  appearance ;  on  the  other  hand,  con- 
stant cheerfulness,  with  an  expression  of  mildness  in  the 
laughing  features  and  gentle  eyes.  The  dull  idiot  is 
usually  roused  with  difficulty  from  his  brooding,  unless  an 
interrupted  impulse  becomes  manifest  in  unexpected  vio- 


356  HANDBOOK   OF  INSANITY. 

lent  outbreaks  of  rage,  directed  not  infrequently  against 
his  own  person.  In  the  mobile  idiot,  on  the  other  hand, 
the  attention  is  directed  hither  and  thither,  and  the  external 
restlessness  is  also  shown  by  the  clapping  of  the  hands, 
purposeless  jumping  about,  laughing  and  shouting.  Their 
endeavors  are  stimulated  mainly  by  impulses,  chief  among 
which  is  the  need  of  food ;  in  great  part  this  forms  the 
central  point  of  all  their  mental  processes.  In  the  highest 
grades  of  idiocy  all  objects  are  put  into  the  mouth ;  help- 
less, filthy,  without  any  manifestations  of  mind,  the  activ- 
ity of  such  an  individual  is  confined  to  the  gratification 
of  his  few  impulses.  The  sexual  sense  is  sometimes  man- 
ifested periodically,  as  in  rutting  animals,  but  the  fre- 
quent inhibition  in  the  development  of  the  genital  appara- 
tus is  usually  accompanied  by  feeble  sexual  desire. 

The  motor  impulse  is  often  restricted  by  motor  disturb- 
ances of  various  kinds.  These  include  spasms,  which  may 
be  confined  to  the  toes,  one  arm  or  leg,  may  appear  as 
unilateral  athetosis,  or  may  exhibit  the  signs  of  chorea  or 
epilepsy.  The  latter  variety  is  the  most  frequent  and 
greatly  impairs  the  prognosis.  As  a  general  thing,  idiocy 
remains  at  its  original  degree  of  intensity,  but  progressive 
advance  is  to  be  apprehended  when  it  becomes  associated 
with  epilepsy. 

Some  idiots  suffer  from  paralytic  conditions  of  the  limbs. 
Many  can  neither  stand  nor  walk,  in  others  there  is  diffi- 
culty of  maintaining  equilibrium  while  walking.  In  ad- 
dition, spasmodic  movements  of  the  legs  are  frequent. 
There  may  also  be  disease  of  the  spinal  cord,  shown  by 
atrophy  of  individual  groups  of  muscles  and  contractures 
of  the  limbs.  In  the  more  severe  grades  of  idiocy,  symp- 
toms which  indicate  grave  anatomical  lesions  are  rarely 
absent.  Even  in  the  milder  cases  we  find  not  alone  a 
feeble  posture,  uncertain  gait,  and  awkward  use  of  the 
hands,  but  there  are  also  various  indications  of  spastic 
and  paralytic  affections,  imperfect  development,  or  atrophy 
of  certain  muscles  or  of  an  entire  half  of  the  body.  When 
the  body  presents  no  physical  deformity,  as  in  the  mobile, 


DIAGNOSIS.  357 

excited  variety,  the  constant  rocking  and  swaying  move- 
ments remind  us  of  chorea,  and  show  by  their  useless 
character  that  they  are  imperative  movements  of  direct 
cerebral  origin ;  or  they  are  a  sort  of  play,  as,  for  example, 
blowing  with  the  mouth,  accompanied  often  by  monoto- 
nous singing  and  murmuring  tones  which  seem  to  have  a 
sort  of  rlrythm. 

The  motor  disturbances  also  include  difficulty  in  speak- 
ing, but  this  does  not  always  show  the  degree  of  idiocy, 
because  there  may  be  relatively  good  comprehension  of 
things  heard.  But  the  excessive  use  of  infinitives  and 
certain  interjections  shows  that  intellectual  weakness  of 
central  origin  exists  as  often  as  interference  with  speaking. 

Distinct  as  the  mental,  weakness  or  the  entire  absence 
of  mental  activity  may  be,  the  differentiation  between 
idiocy  and  imbecility  becomes  more  difficult  when  the 
bodily  errors  of  development  are  less  distinct.  Idiots  of 
milder  grades  may  become,  in  a  measure,  useful  members 
of  society,  inasmuch  as  they  may  learn  some  occupation 
to  which  they  devote  their  entire  attention ;  an  imbecile  is 
often  lacking  in  the  necessary  endurance  and  desire  to 
work.  The  achievements  of  the  idiot,  however,  are  like 
those  of  a  machine :  he  has  no  power  of  utilizing  what  he 
has  learned  in  an  independent  manner,  and  the  standstill  at 
a  certain  stage  of  development  is  complete.  The  boundary 
is  usually  reached  at  the  period  of  puberty,  if  not  earlier. 

It  is  evident  from  the  clinical  similarity  in  the  signs  of 
feeble-mindedness  after  other  psychoses  and  those  of  con- 
genital or  early  acquired  idiocy  that  both  forms  are  dif- 
ferentiated with  difficulty.  It  is  important,  however,  to 
distinguish  all  these  forms  of  feeble-mindedness,  which 
remain  stationary  at  a  certain  point,  from  those  conditions 
of  mental  weakness  which  tend  to  progressive  dementia 
and  which  we  have  alreadj^  studied  in  discussing  the  vari- 
ous groups  of  mental  diseases.  The  prognosis  of  imbecil- 
ity and  idiocy  is  entirely  unfavorable  as  regards  recovery, 
and  improvement  can  only  be  effected  by  pedagogic  meas- 
ures.    In  the  higher  grades  of  idiocy  the  patients  are  sub- 


358  HANDBOOK   OF   INSANITY. 

ject  to  various  injurious  influences  which  shorten  life,  such 
as  injuries,  digestive  disturbances,  and  especially  pulmo- 
nary tuberculosis. 

Idiots  should  be  sent  as  early  as  possible  to  an  idiot 
asylum.  In  older  idiots  and  in  the  other  forms  of  imbe- 
cility described  in  this  section  the  treatment  is  merely 
directed  against  the  individual  symptoms.  The  inatten- 
tive imbecile  may  be  led  by  flatteries  and  rewards,  and 
his  activities  may  be  called  forth  by  strict  regulations. 
In  an  idiot  of  higher  grade  such  measures  are  useless. 
On  account  of  their  timidity,  imbeciles  are  usually  con- 
trolled easily  by  punishment,  but  this  should  be  adminis- 
tered when  they  are  alone,  inasmuch  as  the  presence  of 
others,  when  they  are  scolded  or  when  food  or  other  means 
of  gratification  are  denied,  induces  them  to  play  the  part 
of  a  martyr.  Hence  isolation  for  a  few  hours  is  often  the 
most  simple  method  of  bringing  an  imbecile  to  terms. 
Otherwise  they  must  be  kept  under  constant  supervision, 
as  they  are  apt  to  tear  their  clothes  when  angry  or  even 
to  befoul  themselves  in  order  to  annoy  the  attendants. 

The  description  of  imbecility  and  idiocy  has  shown 
widely  divergent  conditions  at  both  ends  of  the  entire 
series,  but  it  has  not  revealed  undoubted  differences  in  the 
varieties  found  at  the  middle  of  the  series.  For  this  reason 
we  regard  it  as  impracticable  to  ask  for  a  decisive  differ- 
ence in  treatment,  such  as  has  been  practised  in  France. 
It  is  there  held  that  the  imbecile,  on  account  of  his  selfish, 
malicious,  dangerous,  and  incorrigible  impulses  and  acts, 
is  directly  antagonistic  to  the  common  interests  of  societj^, 
while  the  imperfectly  developed  but  good-humored  idiot, 
who  is  susceptible  of  education  to  a  certain  degree,  is  in- 
nocuous. Hence,  the  anti-social  imbecile  should  be  sent 
to  a  reformatory,  the  extra-social  idiot  to  a  hospital.  It 
appears  to  us,  however,  to  be  too  difficult  to  decide  each 
case  in  accordance  with  this  principle,  especially  as  the 
border  conditions  are  very  numerous.  Such  a  distinction 
would  also  possess  the  greatest  judicial  importance  and 
would  necessitate  changes  in  the  criminal  law. 


DESCRIPTION  OF  PLATE  X. 

FEEBLE-MINDEDNESS. 

The  first  picture  illustrates  acquired  feeble- mindedness  after  a 
simple  mental  disorder  on  a  normal  cerebral  basis.  The  picture  of 
the  scornfully  smiling  old  woman  hardly  requires  an  explanation ; 
the  wrinkling  of  the  brows  is  probably  due,  in  part,  to  the  ex- 
cessively bright  illumination. 

The  woman  to  the  right  suffers  from  congenital  feeble-minded- 
ness  or  imbecility.  She  entered  the  asylum  on  account  of  anxious 
excitement,  but  is  now  cheerful  and  content. 

The  picture  of  the  young  man  on  the  left  shows  some  signs  which 
have  been  regarded  as  characteristic  of  moral  insanity.  It  exhibits 
a  congenital  criminal.  Of  illegitimate  birth,  he  early  began  to  steal 
under  the  guidance  of  his  mother,  constantly  read  tales  of  robbery, 
and  expatiated  upon  them  in  poetical  prolix  dissertations  which 
evinced  feeble-mindedness  in  various  directions.  His  impudent 
conduct  in  prison  finally  led  to  a  diagnosis  of  insanity  and  he  was 
admitted  to  the  asylum.  It  will  not  be  conceded  that  he  has  "  a 
murderer's  eye,"  as  he  himself  maintains;  but  the  general  impres- 
sion of  criminality  is  increased  by  the  following  characteristic 
signs,  viz.,  scanty  beard  with  thick  curly  hair  on  the  head,  promi- 
nent chin,  short  upper  lip,  short  nose. 

The  young  man  on  the  right  side  is  an  idiot  of  moderate  grade 
since  childhood.  The  relative  predominance  of  the  face  over  the 
calvarium,  the  sunken  nose,  and  the  imbecile  laugh  enable  us  to 
recognize  the  idiot  even  without  gross  deformities  of  the  skull  and 
signs  of  degeneration. 


HANDBOOK  OF  INSANITY. 

KIRCHHOFF. 


Plate  X. 


INDEX. 


Acquired     feeble  -  mindedness, 
346 

Activity,  mental,  the  brain  the 
site  of  the,  5 

Acute  neurasthenia,  330 

Affections,  syphilitic,  298 

Affective      insanity,      constitu- 
tional, 118 

Affects,  sensual  and  higher  feel- 
ings, 84 

Age,  relation  of,  to  insanity,  24 

Agitated  dementia,  261 

Alcoholic  epilepsy,  344 
insanity,  acute,  339 

Alcoholism,  41 
chronic,  336 

Anaemia    and   exhausting    dis- 
eases of  internal  organs,  36 

Anatomy,  pathological,  17 

Apathetic  dementia,  261 

Aphasia,  13 

Apperception  and  association,  68 

Articulation,  disorders  of,  273 

Artificial  feeding,  163 

Asylums  and  their  advantages, 
166 
insane,  erection  of,  174 

Atrophy  of  the  brain,  partial,  353 

Auditory  hallucinations,  53 

Aura,  epileptic,  303 

Bodily    and   mental   retrogres- 
sion, 28 
treatment,  155 
Border  lines,    the,   of  insanity, 

147 
Brain,  developmental  history  of 
the,  4 
imperfectly  developed,  9 
fissures,    mode    of    develop- 
ment of  certain,  5 
partial  atrophy  of  the,  353 
the,  and  its  membranes,  33 
the,    as  the  site  of  normal 
mental  processes,  4 


Catalepsy,  65 

Causes  of  insanity,  classification 
of  the,  20 
of  neurasthenia,  328 
psychical,  42 
Centres,    the   centi'o-motor    and 

visual,  15 
Cerebral    development,     imper- 
fect, 351 
sclerosis,  diffuse,  299 
syphilis,  296 
Changes,  vessel,  297 
Character,  the  epileptic,  305 
Childbed,    connection   between, 

and  insanity,  39 
Childhood,    causes    of    insanity 

in,  24 
Chronic  alcoholism,  336 
Circular  insanity,  223 

insanity,  clinical  history  of, 
225 
Civilization  a  cause  of  insanity, 

21 
Classification  of  insanity,  183 

simple,  8 
Combined  hallucinations,  61 
Complaints,       hypochondriacal, 

324 
Conceptions,  language,  14 
Confusion,  254 
Congenital     feeble-mindedness, 

347 
Contents  of  delusions,  133 
Convalescents,  treatment  of,  166 
Co-ordinate  value  of  the  hemi- 
spheres, 12 
Cord,  nerves,  and  sympathetic, 
coincident  diseases  of  the,  35 
Course  of  ideas,  accelerated  and 

retarded,  70 
Cretinism,  353 
Crime  and  genius,  32 

Degeneration,  epileptic,  308 
Delirium  tremens,  341 


359 


360 


INDEX. 


Delirium  tremens,  treatment  of, 

342 
Delusional  system,  239 
Delusion  of  persecution,  237 
Delusions,  72 

of  grandeur,  243 
Dementia,  agitated,  261 
apathetic,  261 
mobile,  261 
paralytic,  266 
primary,  259 
secondary,  261 
senile,  262 

with  paralysis,  forms  of,  296 
Depression  in  dementia,  285 
Development,     imperfect    cere- 
bral, 351 
Diagnosis  of  recovery,  145 

the,  of  mental  disorders,  129 
Diffuse  cerebral  sclerosis,  299 
Dipsomania,   96 

Diseases,  coincident,  of  the  cord, 
nerves,  and  sympathetic, 
35 
focal,  in  relation  to  mental 

disturbances,  9 
of  the  brain,  focal,  300 
of  the  sexual  organs,  37 
Disorders,      mental,     associated 
with  general  diseases,  258 
mental,  simple,  186 
mental,  with  neurasthenia, 

320 
of  articulation,  273 
of  self-consciousness,  66 
phonetic,  275 
Disturbance,  mental,  meningitis 

may  lead  to,  34 
Disturbances,  mental,  explained 
by   psychological    consid- 
erations, 9 
mental,  the  anatomical  basis 
and  the  location  of,  3 
Dream  states,  307 

Education  and  insanity,  32 
Empirical    science,     psychiatry 

an,  3 
Epidemics,  psychical,  due  to  re- 
ligious causes,  44 
Epilepsy,   alcoholic,  344 
mental  disease  in,  301 
treatment    of  mental  disor- 
ders of,  310 
Epileptic  aura,  303 
character,  the,  305 
degeneration,  308 


Epileptiform  paralytic  attacks, 

281 
Erection  of  insane  asylums,  174 
Erotic  and  religious  symptoms, 

249 
Expressive  movements,  100 

Fantasy,  disorders  of  memory 

and,  78 
Fear,  precordial,  189 
Fears,  morbid,  in  neurasthenics, 

323 
Febrile  diseases  and  poisoning, 

39 
Feeble-mindedness,  acquired,  346 

congenital,  347 
Feeding,  artificial,  163 
Feeling,  hallucinations  of,  58 
Fissures,  brain,   mode  of  devel- 
opment of  certain,  5 
significance  of  the,  6 
Focal    diseases    in    relation    to 
mental  disturbances,  9 
diseases  of  the  brain,  300 
Forms,  periodical,  216 
Frenzy,  207 
Function  of  speech,  the,  12 

Gait,  279 

General   diseases,  mental  disor- 
ders associated  with,  258 
Genius,  crime  and,  32 
Gliosis,   299 

Grandeur,  delusions  of,  243 
"  Gruebelsucht, "  70 
Gynecological  examinations,  13ft 

Hallucinations,  auditory,  53 

combined,  61 

of  feeling,  58 

olfactory,  56 

originating  in  viscera,  59 

unilateral  auditory,  18 

visual,  47 
Head,  injuries  to  the,  35 
Hebephrenia,  27 
Hemispheres,   co-ordinate  value 

of  the,  12 
Heredity,  29 

History,  clinical,  of  circular  in- 
sanity, 225 

developmental,  of  the  brain,. 
4 

of  psychiatry,  168 
Hypnosis,  64 
Hypnotics,  158 

restraint  and,  215 


INDEX. 


361 


Hypochondriacal  complaints,  324 
Hysteria,  insanity  and,  311 
Hysterical  insanity,  317 
seizures,  313 

Idiocy,   354 

Imbecility,  347 

Imperfectly  developed  brain,  9 

Impulsive  movements,  91 

Injuries  to  the  head,  35 

Insane,  present  treatment  of  the, 
178 

Insanity,  acute  alcoholic,  339 
and  hysteria,  311 
circular,  223 

civilization  a  cause  of,  21 
classification  of,  183 
classification  of  the   causes 

of,  20 
connection    between    child- 
bed and,  39 
education  and,  32 
hysterical,  317 
in  childhood,  causes  of,  24 
localization  in,  19 
of  querulents,  250 
pellagrous,  23 
pregnancy  and,  38 
prevention  of,  154 
real  or  simulated,  146 
relation  of  age  to,  24 
the  border  lines  of,  147 
the  treatment  of,  151 

Internal    organs,     angemia    and 
exhausting  diseases  of,  36 

Language  conceptions,  14 

relations    of,     with    mental 
•  life,  15 
Localization  in  insanity,  19 
Loss  of  memory,  80 

Mania,  201 

periodical,  220 
psychical  treatment  of,  216 
Melancholia,   186 
periodical,  218 
treatment  of,  198 
Meningitis  may  lead  to  mental 

disturbance,  34 
Mental  activity,    the  brain  the 
site  of  the,  5 
disease  in  epilepsy,  301 
disorders    at   the  period   of 

puberty,  26 
disorders  due  to  poisons,  332 


Mental    disorders    of    epilepsy, 
treatment  of,  310 
disorders,  simple,  186 
disorders,  the  course  of,  114 
disorders,   the  diagnosis  of, 

129 
disorders,  the  signs  of,  45 
disturbances  based  on  path- 
ological anatomy,  9 
disturbances,  the  anatomical 
basis     and    the     location 
of,  3 
life,    relations  of    language 
with,  15 
Microcephalus,  simple,  352 
Mobile  dementia,  261 
Morphinism,  333 

Neurasthenia,  acute,  330 

causes  of,  328 
mental  disorders  with,  320 
Neurasthenics,  morbid  fears  in, 

323 
Normal  and  morbid  impulses,  148 
mental  processes,  the  brain 
as  the  site  of,  4 

Occupation,  33 
Olfactory  hallucinations,  56 
Opposition    to    mechanical    re- 
straint, 175 
Overwork,  worry  and,  43 

Paralysis,  forms   of   dementia 

with,   296 
Paralytic  attacks,  epileptiform, 
281 
dementia,  266 
Paranoia,  230 
Pathological  anatomy,  17 

anatomy,     mental    disturb- 
ances based  on,  9 
Pellagrous  insanity,  23 
Perception,  visual,  disturbances 

of,  16 
Perceptive  process,  disturbances 

of  the,  46 
Periodical  forms,  216 
mania,  220 
melancholia,  218 
Persecution,  delusion  of,  237 
Phonetic  disorders,  275 
Physical    symptoms,     concomi- 
tant, 107 
Physician,  personality  of  the,  152 
Poisoning,  febrile  diseases  and, 
39 


362 


INDEX. 


Poisons,    mental   disorders   due 

to,  332 
Post-mortem  findings,  150 
Praecordial  fear,  189 
Pregnancy  and  insanity,  38 
Prevention  of  insanity,  154 
Primary  dementia,  259 
Prognosis,  general,  122 
Pseudaphasic  confusion,  104 
Psychiatric  examination,  131 
Psychiatry  an  empirical  science, 
3 
history  of,  168 
Psychical  causes,  42 

epidemics  due  to  religious 

causes,  44 
trauma,  20 

treatment  of  mania,  216 
Psychological       considerations, 
mental  disturbances  explained 
by,    9 
Psychoses,  periodical,  117 
Puberty,  mental  disorders  at  the 

period  of,  26 
Pupillary  symptoms,  277 

Querulents,  insanity  of,  250 

Raptus  melancholicus,  191 
Real  or  simulated  insanity,  146 
Recovery,  diagnosis  of,  145 
Removal  from  asylum,  201 
Restraint  and  hypnotics,  215 
mechanical,    opposition   to, 
175 
Retrogression,  bodily  and  men- 
tal, 28 

Secondary  dementia,  261 

Seizures,  hysterical,  313 

Self- consciousness,  disorders  of, 

66 
Senile  dementia,  262 
Sexual  organs,  diseases  of  the, 
37 
sensations,  contrary,  98 
Significance  of  the  fissures,  6 
Signs,  the,  of  mental  disorders, 

45 


Simple  classification,  8 

microcephalus,  352 
Somnolence,  63 
Speech,  the  function  of,  12 
States,  dream,  307 
Statistics,  value  of,  21 
Status  epilepticus,  308 
Suicide  as  an  impulse,  94 

prevention  of,  165 
Superstition,  influence  of,  171 
Symptoms,  erotic  and  religious, 
249 

important,  treatment  of,  161 

pupillary,  277 
Syphilis,  cerebral,  296 
Syphilitic  affections,  298 
System,    delusional,  239 

Terror  and  allied  feelings,  89 

The  brain  and  its  membranes,  33 

Trauma,  psychical,  20 

Treatment,  bodily,  155 
of  convalescents,  166 
of  delirium  tremens,  342 
of  important  symptoms,  161 
of  insanity,  the,  151 
of  melancholia,  198 
of  the  insane,  present,  178 

Trophic  functions,  disorders  of 
the,  110 

Typhoid  fever,  145 

Unilateral  auditory  hallucina- 
tions, 18 

Value  of  statistics,  21 
Verruecktheit,  236 

without  hallucinations,  246 
Vessel  changes,  297 
Viscera,     hallucinations    origi- 
nating in,  59 
Visual  centres,  the  centro- motor 
and,  15 
hallucinations,  47 
perception,  disturbances  of, 
16 

Wahnsinn,  231 

Worry  and  overwork,  43 


I 


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